Transitional Care Nurse, Primary Care

Beth Israel Lahey Health

. Coordinate care management for medically complex, high-risk primary care patients discharged from acute or sub-acute inpatient facilities .

Posted 9/22/2026full-timeBoston • Massachusetts • United StatesMid-LevelSenior💰 $32 - $55 per hourWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in care management for high-risk patients, including discharge planning, medication reconciliation, and patient education. Proficient in telephonic patient assessments and collaboration with healthcare teams to enhance care transitions.

Highest-signal resume keywords

Registered Nurse LicenseNursing Case ManagementChronic Care Management (CCM)Discharge PlanningTelephonic Patient Interaction

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Patient AssessmentMedication ReconciliationCare CoordinationClinical DocumentationHealth Coaching

Soft Skills

Detail OrientedEffective CommunicationTeam CollaborationPatient Engagement

Tools & Technologies

Electronic Health Record (EHR)Microsoft OutlookMicrosoft WordMicrosoft ExcelMicrosoft PowerPoint

Certifications & Qualifications

Basic Life Support Certificate

Industry Keywords

NursingAcute CareSub-Acute CareVNA SkillsMedical/Surgical Experience

About the role

Key responsibilities & impact

Coordinate care management for medically complex, high-risk primary care patients discharged from acute or sub-acute inpatient facilities
Perform telephonic patient assessments using discharge summaries and patient/caregiver information
Identify early health issues and potential barriers to discharge plans
Complete discharge medication reconciliation and identify discrepancies or adherence barriers
Document encounters accurately in the medical record/EHR according to BIDHC protocols
Review discharge instructions and coordinate follow-up labs, diagnostic studies, specialty appointments, and primary care appointments
Provide health coaching and education to patients/caregivers
Encourage patient self-engagement and identify barriers to adherence
Identify clinical issues and lapses in standards of care and notify appropriate providers and staff
Collaborate with providers and practice team members to ensure the plan of care is met
Provide clinical and educational consultation to patients/caregivers
Support BIDHC practice locations and improve care transitions

Requirements

What you’ll need

Graduate from an accredited Nursing Program required
Bachelor's degree in Nursing preferred
Registered Nurse license preferred, or Licensed Practical Nurse (LPN)
American Heart Association – Basic Life Support Certificate required
3-5 years related work experience required
Detail oriented with the ability to work in a fast paced, high call volume team environment
Advanced skills with Microsoft applications, including Outlook, Word, Excel, PowerPoint or Access, and other web-based applications
Advanced computer skills, including email, typing, and accessing work systems
English communication skills for written and oral communication
Previous nursing case management or medical/surgical experience preferred
VNA skills preferred
Nursing telephone triage, Chronic Care Management (CCM), discharge planning, skilled telephonic patient interaction, and primary care/ambulatory care experience preferred

Benefits

Comp & perks

Initial onsite training in the North Shore area
Influenza vaccination required as a condition of employment
Equal Opportunity Employer/Veterans/Disabled