RN Case Manager

Location: Woburn, MA
Job ID: 178110-1A
Date Posted: Aug 15, 2022
Category: Nursing

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Job Description

Welcome To

Welcome To Beth Israel Lahey Health at Home. Our team provides high-quality home care and hospice services by partnering with physicians, hospitals and skilled nursing facilities to provide specialized care to patients in the comfort of their own home. Our team of nurses, therapists (physical, occupational, and speech), medical social workers, and home health aides work together to devise and implement a compassionate care plan that is expressly tailored for each patient.

About the Job

Position Summary: 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 the individuals and families within their homes and communities in accordance with home care regulations and payer guidelines.

About Us

Beth Israel Lahey Heath is dedicated to improving health and wellness and making a difference in the lives of our patients, their families and all members of the communities we serve. Formed in March 2019, Beth Israel Lahey Health is a patient-centered, integrated care delivery system providing a continuum of services spanning academic, tertiary and community hospitals, dedicated orthopedic and psychiatric hospitals, primary and specialty care, community acute care, ambulatory care, behavioral services and home health.

Equal opportunity Employer/Minorities/Females/Disabled/Veterans.


Essential Duties and Responsibilities including but not limited to:

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. Inititates 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.
  11. Demonstrates proficiency in OASIS completion.
  12. Clinical visit notes explain the need for 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.
  13. Completes documentation in accordance with agency timeliness policies.
  14. Participates in the weekend/holiday/on-call rotation as defined by Lahey Health at Home.


Minimum Qualifications:


  • 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
  • Has an active American Heart Association BLS. If no American Heart Association BLS the employee must complete an annual BILHAH BLS Competency. No other forms of BLS will be accepted.


  • 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 with 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 worrk with minimal supervision
  • Shows strong ability to organize and prioritize workload independently; nursing skills per competency checklist