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Nurses at Lahey Hospital & Medical Center practice patient-focused care in the operating room and in perioperative medicine, in medical/surgical and critical care inpatient units, in ambulatory clinics and as members of interdisciplinary teams.

RN Case Manager, Lahey Health at Home, Full time - Days

Job ID 140212 Date posted 12/29/2016
Job Description

The registered nurse plans, organizes and directs home care services and is experienced in nursing, with emphasis on community health education/experience. The professional nurse builds from the resources of the community to plan and direct services to meet the needs of individuals and families within their homes and communities in accordance with home care regulations and payer guidelines.

Patient Care
Assumes responsibility to coordinate patient care for assigned caseload including but not limited to:
1. Appropriate delegation to LPN staff, patient condition change visits, and completion of OASIS time points. Accepts accountability for patient satisfaction scores and quality of care outcome measure results.
2. Completes and documents an initial assessment of patient and family to determine home care needs. Provides a complete physical assessment and history of current and previous illness(es).Develops a patient specific plan of care, which establishes goals based on nursing diagnosis and incorporates therapeutic, preventive, and rehabilitative nursing actions. Includes the patient and the family in the planning process.
3. Initiates the plan of care and makes necessary revisions as patient status and needs change.
4. Initiates appropriate preventive and rehabilitative nursing procedures. Administers medications and treatments as prescribed by the physician.
5. Counsels the patient and family in meeting nursing and related needs.
6. Respects and supports patient and family's cultural beliefs and values, individual needs, health goals and treatment preferences.
7. Provides health care instructions to the patient as appropriate per assessment and plan of care.
8. Instructs, supervises and evaluates home health aide care provided every two (2) weeks.
9. Manages episode of care in accordance with evolving nursing care needs and continued eligibility for services.
10. Identifies discharge planning needs as part of the care plan development and implements prior to discharge of the patient.
1. Communicates with the physician regarding the patient?s needs and reports any changes in the patient?s condition; obtains/receives physician?s orders as required.
2. Attends regular case conferences and team meetings per Clinical Manager and as needed.
3. Communicates with team LPN when delegating appropriate visits.
4. Communicates with other community providers to coordinate the care plan (i.e. Insurance case managers, high risk case managers, elder services, protective service, etc.).
5. Practices confidentiality principles set by the agency and federal HIPAA guidelines.
1. Demonstrates proficiency in OASIS completion
2. Clinical visit notes explain the need for the skilled nursing service in light of the patient?s overall medical condition and experiences; the complexity of the services performed and the plan for the next visit based on the rationale of prior results.
3. Completes documentation in accordance with agency timeliness policies.
Professional Development
1. Maintains and updates clinical knowledge and skills based on current nursing practice.
2. Adheres to departmental requirements for required training.
3. Identifies specific learning needs & goals and collaborates with nursing leadership in developing a plan to meet them.
Additional Duties
1. Participates in the weekend/holiday/on-call rotation as defined by Lahey Health at Home.
2. Ensures that arrangements for equipment and other necessary items and services are available.
3. Participates in in-service programs and supervises, teaches and precepts other nursing personnel as assigned by Clinical Manager.


- Registered Nurse from a Graduate of National League for Nursing accredited school of nursing
- BSN, strongly preferred

Licensure, Certification & Registration:
- Registered nurse with current licensure to practice professional nursing in the state of Massachusetts.
- Maintains a current American Heart Association (AHA) CPR certification.
- Minimum of 1-2 years nursing experience, at least one of which is in the area of public health or home care nursing with OASIS experience is preferred.
Skills, Knowledge & Abilities:
- Demonstrates excellent observation and problem solving/critical thinking skills.
- Well-developed verbal and written communication skills; essential computer skills to work with EMR.
- Must be a licensed driver with an automobile that is insured in accordance with state or organization requirements and is in good working order.
- Self-directed and able to work with minimal supervision
- Shows strong ability to organize and prioritize workload independently; nursing skills per competency checklist.


Weekdays with weekend, on-call and holiday rotation
About Lahey Health

Lahey Health at Home - Quality Care Where Our Patients Live

Nothing promotes health and healing, while maintaining independence and dignity, more than receiving care in a comfortable and familiar environment. Our team of clinicians at Lahey Health at Home find solutions that allow individuals recovering from an illness, injury, surgery or who learning to manage a chronic illness, restore their health in the very place they feel most comfortable-- their own home.

By partnering with physicians, hospitals and skilled facilities, our clinicians help individuals make a seamless transition back home. How? With an experienced team of nurses, therapists (physical, occupational and speech), medical social workers, and home health aides whose one goal is patient-centered quality care.

We're especially proud of the recognition we have received for our work. These acknowledgements of exceptional service and the highest level of care translate directly into peace of mind for you.

* HomeCare EliteTM, which annually names the top 25 percent of home health agencies in the United States based on quality of care, quality improvement and financial performance, first named Lahey Health at Home to its select list in 2011 and annually thereafter.
* Home Health Quality Improvement National Campaign Agency of the month (AOTM)
* Fazzi Associates has also honored us with its Patient Satisfaction Award of Distinction, presented annually to home health organizations that have demonstrated superior performance in overall patient satisfaction results.

When you choose to work at Lahey Health at Home, you choose to deliver exceptional care with compassion expressly tailored for each individual. Join our team and our mission of excellence by applying today!

How To Apply

Please apply directly online at Once you have located the desired job, click on the checkbox in the 'Select' column, and then click the 'Apply Now' button, located at the bottom of the screen.

Lahey Colleagues please apply directly through Colleague Connection using your Login and Password.

Contact: Laurie Marcotte, Recruiter at 781-756-7707