Referral Case Manager RN- (Burlington)

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Location: Woburn, MA
Job ID: 160099-1A
Date Posted: Mar 9, 2020
Category: Nursing

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Job Description

Welcome To

Welcome to Lahey Hospital & Medical Center, part of Beth Israel Lahey Health. Lahey Hospital & Medical Center is a world-renowned tertiary medical center known for its innovative technology, pioneering medical treatment and leading-edge research. A teaching hospital of Tufts University School of Medicine, the hospital provides quality health care in virtually every specialty and subspecialty, from primary care to cancer diagnosis and treatment to kidney and liver transplantation. It is a national leader in a number of health care areas, including stroke, weight management and lung screenings, among many others. Lahey also helps to advance medicine through research and the education of tomorrow's health care leaders.

About the Job

Under the general supervision of the Executive Director, practices within the Lahey Clinic Professional Practice Model, MA Nurse Practice Act, ANA Standards of Practice and Code of Ethics and demonstrates Lahey Clinic’s core values that reflect its Mission. The Referral Case Manager facilitates collaboration, communication and care coordination with all members of the healthcare team to support the patient across the health care continuum.  The Referral Case Manager is an integral member of the health care team who works to ensure safety, best practice and high quality standards of care are maintained across the continuum of care for identified patient populations.    The RN II / Population Health NurseCase Manager will assess, plan, implement and evaluate comprehensive, coordinated health services for the identified patient population to support their achievement of the highest level of self-management.


The Referral Case Manager, in accordance with the Nurse Practice Act of Massachusetts Rules and Regulations – 244 CMR 3.0, shall bear full and ultimate responsibility for the quality of nursing care he/she provides to individuals and groups.  Responsibilities include health maintenance, teaching, counseling, collaborative planning and basic clinical decision support resources.   



Essential Duties & Responsibilities including but not limited to:

Clinical Judgment and Decision Making: Ways in which nurses come to understand the problems, issues or concerns of patients/families, to attend to relevant/critical information, and to respond in concerned and involved ways.

    • The Referral Case Manager is expected to and is accountable for providing safe patient care by demonstrating organizational skills that maintain and coordinate safe delivery of quality care for assigned patients/families.
    • Delivers care that is specific to the age of the patient.
    • Evaluates effectiveness of care and adapts plan based on patient/family response.
    • Responsible for coordinating referrals within the system by way of educating patients to resources within the system.
    • Provides education of available services and review of patient health maintenance.
    • Redirects outside referrals within 48 hours.
    • Assists patients with issues and concerns pertaining to the patient care needs.


Professional Relationship: The professional relationship is based upon Lahey Clinic’s guiding principles and positive effective communication. This relationship extends beyond formal assessment to integrate the particular patient’s response and his/her religious/spiritual, ethnic and cultural beliefs into the plan of care.

    • Establishes professional relationship with nurses, physicians and other colleagues and patients and families.
    • Supports Lahey Clinics commitment to community based activities both within the Lahey community and beyond.


Clinical Leadership:  The Ambulatory and Transitional Case Manager supports the development of others and creates a practice climate of responsiveness and learning.  This supports the retention and recruitment of clinically competent nurses.   The ability to lead and influence the reasoning of colleagues in the patient’s best interest depends on skillful comportment, authoritative clinical knowledge and wisdom, the conviction to act as an ethical agent despite adverse consequences, and the ability to listen and enhance others’ strengths. 

    • Demonstrates professional behavior by adhering to unit policies and procedures, practice guidelines specific to the setting and the ANA Code of Ethics.
    • Demonstrates skills as a responsive team member.
    • Demonstrates clinical leadership as evidenced by supporting research and development of clinical pathways.
    • Demonstrates role of nurse as teacher.
    • Demonstrate ability to fulfill role in Regulatory compliance and readiness.


Case Management: Coordinates care for identified patients across the continuum in collaboration with physicians and all members of the health care team

  • Serves as the liaison with patients, families to physicians, clinical staff, iand other departments within Lahey, 3rd party insurers involved with patient care, and community and post-acute care providers.
  • Advocates for patient and families, responds to and facilitates resolution of patient questions and concerns.
  • Conducts comprehensive clinical assessments that include the age-specific, medical, behavioral, pharmacy and social needs of each patient.  Shares this information with the healthcare team and with the patient.  Partners with patients and families on self management support including:                                                                              Sets short and long-term goals for self-management of chronic disease to include acute exacerbation management.
  • Performs reassessment in patient progress toward goals and alters plan of care as appropriate.
  • Works with patient to create a plan for health behavior change.
  • Assesses and works with the patient’s readiness to change, the importance of change, and confidence in ability to change.
  • Helps the patient to identify and overcome barriers.
  • Provides or arranges needed patient education regarding specific health care skills and general disease concepts.
  • Works independently to assess and evaluate the patient’s understanding of disease process, treatment plan lifestyle changes, and recognize changes in patient’s condition.
  • Utilizes the disease registry database including: Updates database as appropriate and creates patient, physician, and clinic level quality performance reports.
  • Participates in quality improvement activities aimed to improve patient-population outcomes and associated processes.
  • Assesses clinic needs and collaborates with Clinic/Site manager on strategies to achieve individual clinic level goals, such as quality and efficiency.
  • Actively participates / coordinates committees as needed / requested; i.e., Performance Improvement Teams.
  • Communicates and coordinates with the healthcare team in the development of tools for optimal patient outcomes and report findings.
  • Meets with other Case Managers as indicated by Clinic Administration for standardization in practice, information sharing and continuing education activities.
  • Interacts with case managers and other providing care for the patients in their panel.
  • Will respond to Payer requests for clinical information needed to certify an admission and reimburse for services, by providing appropriate clinical information within one business day of the request; documents communication with payer.
  • Will work with the Stop Loss Carriers to effectively management High Dollar Claims.
  • Monitors and identifies problems of inappropriate utilization of resources.
  • Make referrals as needed to the Medical Director.
  • Assists with appeal of services denied.


Additional Duties and Responsibilities:

Obtains bachelor’s degree within 5 years of start date.





Organizational Requirements:

Maintain strict adherence to the Lahey Hospital and Medical Center Confidentiality policy.

Incorporate Lahey Hospital and Medical Center Standards of Behavior and Guiding Principles into daily activities

Comply with all Lahey Hospital and Medical Center Policies.

Comply with behavioral expectations of the department and Lahey Hospital and Medical Center.

Maintain courteous and effective interactions with colleagues and patients.

Demonstrate an understanding of the job description, performance expectations, and competency assessment.

Demonstrate a commitment toward meeting and exceeding the needs of our customers and consistently adheres to Customer Service standards.

Participate in departmental and/or interdepartmental quality improvement activities. 

Participate in and successfully completes Mandatory Education.

Perform all other duties as needed or directed to meet the needs of the department.



Minimum Qualifications:


Bachelor’s degree in Nursing. In the absence of a Bachelor’s degree, 8 years of experience in addition to the experience requirement listed below.

Licensure, Certification & Registration:


Licensed RN in the Commonwealth of Massachusetts.




A minimum of 5 years medical/surgical or ambulatory clinic nursing required.


Skills, Knowledge & Abilities:

Demonstrates expert practice skills that include flexibility, priority setting, problem-solving, conflict resolution, negotiating and networking skills, decision making, work delegation and organization, and verbal / written communication skills.

Demonstrates effective teaching techniques applying adult learning principles.

Demonstrates ability to coordinate appropriate educational materials for patients and their support systems.

Demonstrates sound knowledge bases and actions in the decision making process for designated patient populations.

Responsible for following equipment maintenance protocol, identifying problems, and coordinating appropriate repairs.

Answers and routes multiple phone calls and faxes, tasks and directs messages and information pertinent to chronic disease management.

Receives and arranges appointments for providers and patients for patient meetings, procedures, and appointments and sends correspondence as designated.

Adheres to all insurance, contractual and regulatory requirements as mandated.

Excellent interpersonal and organizational skills.



About Us

Beth Israel Lahey Health is an integrated system providing patients with better care wherever they are. Care informed by world-class research and education. We are doctors and nurses, technicians and social workers, innovators and educators, and so many others. All with a shared vision for what healthcare can and should be. We are committed to attracting, developing and retaining top talent. We strive to create a diverse and inclusive workplace that reflects the communities in which we work and serve. With a team approach to care, we encourage learning and growth at all levels and offer competitive salaries and benefits.

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