Care Transition Specialist II BWH
Care Transition Specialist II BWH
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Job Description
Mass General Brigham relies on a wide range of professionals including doctors nurses business people tech experts researchers and systems analysts to advance our mission. As a not-for-profit we support patient care research teaching and community service striving to provide exceptional care. We believe that high-performing teams drive groundbreaking medical discoveries and invite all applicants to join us and experience what it means to be part of Mass General Brigham.
Job Summary
The Care Transition Specialist works collaboratively with Care Coordination to complete administrative responsibilities related to care progression and care transitions along the continuum of care. They work collaboratively with nurse care coordinators social workers physicians and other care team members. The Care Transition Specialist is responsible for acting as an advocate for patients and patient families and strives to support Brigham Healths aim for high quality care high customer satisfaction and optimal resource management. The person in this position will spend time on the clinical units and have direct interaction with patients and their families clinical and ancillary hospital staff and other internal and external customers.1. Provides direct administrative support to the care team patients and patients caregivers related to continuum of care:
a. Supports the administrative tasks and communication related to post discharge care including referrals to internal and external resources such as rehabilitation facilities home health agencies hospice durable medical equipment (DME) providers and other vendors.
b. Actively manages 4Next referrals along the continuum of care including communication with facilities agencies and vendors to promote patient progression to support discharge and effective transitions of care.
c. Secures DME and oxygen for post-acute needs; maps insurance and geography to identify appropriate vendors assesses insurance benefits and coordinates the necessary paperwork with the external vendors and medical team for approval for equipment such as letters of medical necessity medical record documentation and prescriptions. Arranges for and tracks/confirms delivery of equipment prior to or post-discharge.
d. Performs administrative tasks to support the medication prior-authorization function including completion of forms securing medical necessity information and helping to support mitigate barriers for discharge.
e. Assists with the completion of patient follow-up appointments (specialty and PCP) for follow-up care needs.
f. Secures medical records from outside hospital needed to help determine the Acute treatment plan including outreach to outside hospitals completion of forms securing consent from patient or family and securing outside medical record content.
g. Communicates with insurance companies to expedite and/or manage delays with authorization for post-acute care and services or query for covered services
h. Distributes and documents key forms and documents to comply with regulations including Medicare Important Message and Medicare Outpatient Observation Notice. And prepares and submits Medicare Appeal documentation as needed.
i. Arranges all types of patient transportation under the direction of the care team including Med Flight ALS BLS Chair Car Circulation Care Van or Cab Vouchers.
j. Submission of longitudinal transport requests including MassHealth PT-1 and The Ride Applications for patients meeting requirements.
k. Participates in family meetings and interdisciplinary huddles to solicit and provide input related to their responsibilities.
l. Accesses and navigates the electronic medical record to obtain essential information documents progress notes and Resource Specialist Quick Notes as per department standards.
m. Researches and secures out of state and in-network VNAs and facilities.
n. Initiates and/or completes regulatory and other forms such as MassHealth Long-Term Care and DMH/DDS PASSR forms and processes the completed forms with the appropriate agencies.
o. Completes administrative documentation under the direction of the care team.
p. Escalates barriers to discharge.
2. Collects confirms and verifies key patient information (i.e. demographics health care proxy benefit verification and patient preferences for pharmacy facilities VNA etc).
3. Maintains knowledge and reference materials on key resources available to patients and patients caregivers across the continuum:
a. Acts as a knowledge resource for post-acute care resources included but not limited to insurance requirements facility attributes contact information etc.
b. Identifies and refers patients to community services (i.e. transportation food programs day programs and financial programs).
c. Communicates consults and collaborates with a wide range of agencies and ambulatory practices under the direction of the care team.
d. Private care options.
Qualifications
Associate degree required
Bachelors Degree preferred
Health care experience preferably in extended care facilities and community agencies preferred
Preferred experience in hospital discharge planning long term care facility community health or utilization review preferred
Bilingual preferred
Can this role accept experience in lieu of a degree
Yes 7-10 years of experience in a healthcare setting
Knowledge Skills and Abilities
- Assessment and problem-solving skills.
- Strong interpersonal skills.
- Strong Customer service skills.
- Ability to work independently with minimal supervision.
- Goal oriented and accountable in a complex medical environment.
- Experience navigating Insurance Networks desired.
- Demonstrated organizational and time management skills.
- Strong oral and written communication skills.
- Good computer experience.
Additional Job Details (if applicable)
Working hours:
8:00 am - 4:30 pm
8:30 am - 5:00 pm
Weekend and holiday rotation required 8:00 am - 4:30 pm
Hybrid schedule may change due to the needs of the healthcare facility and operations. Weekend and holiday shifts are required to be on-site.
Remote Type
Work Location
Scheduled Weekly Hours
Employee Type
Work Shift
EEO Statement:
Mass General Brigham Competency Framework
At Mass General Brigham our competency framework defines what effective leadership looks like by specifying which behaviors are most critical for successful performance at each job level. The framework is comprised of ten competencies (half People-Focused half Performance-Focused) and are defined by observable and measurable skills and behaviors that contribute to workplace effectiveness and career success. These competencies are used to evaluate performance make hiring decisions identify development needs mobilize employees across our system and establish a strong talent pipeline.
Required Experience:
Unclear Seniority
Employment Type
Full-Time
