Care Transition Specialist II

Site: The Brigham and Womens Hospital Inc.

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 collaborates closely with Care Coordination to manage administrative tasks related to care progression and transitions across the continuum. They work alongside nurse care coordinators social workers providers the Complex Care team and other members of the care team. This role advocates for patients and their families while supporting Mass General Brighams commitment to high-quality care excellent patient satisfaction and efficient resource management. The specialist spends time on clinical units engaging directly with patients their families hospital staff and other internal and external stakeholders.
direct administrative support to the care team patients and patients caregivers related to continuum of care:
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
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.
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.
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.
post-discharge appointments for OB/NICU only.
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
with insurance companies to expedite and/or manage delays with authorization for DME or query for covered services
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.
all tasks in EPIC (in-progress follow-up completed etc.)
all forms of patient transportation as directed by the care team including Med Flight ambulance (ALS BLS) Chair Car Circulation and Boston Cab vouchers
longitudinal transport requests including MassHealth PT-1 and The Ride applications for patients meeting requirements
in interdisciplinary huddles to gather information and provide updates to patients care team
in family/team meetings to solicit and provide input related to their responsibilities
and navigates the electronic medical record to obtain essential information document progress notes and update the Resource Specialist Quick Notes as per department standards
and secures out of state and in-network VNAs and facilities as needed
and submits regulatory documentation such as the MassHealth Long-Term Care paperwork to the appropriate agencies
barriers to discharge to appropriate leadership
HCP and submits to EPIC for upload in EMR
duties as assigned by Resource Center Leadership

Education

High School Diploma required with 3-5 years of healthcare experience

Bachelors Degree Business preferred

Bachelors Degree Related Field of Study preferred


Licenses and Credentials

Experience
Five years of which two must be related to healthcare 5-7 years

Skills/Abilities:

• Interpersonal skills to interact effectively with various levels of staff patients families and community organizations. Must be able to participate effectively in an interdisciplinary team setting.
• Extensive knowledge of regulations community organization state and federal systems medical terminology and levels of health care.
• Must be able to manage a variable workload with the ability to constantly change priorities. Requires ability to work proactively and independently.
• Requires basic typing and/or computer data entry skills experience with personal computer and software desirable.
• Must be very flexible in a constantly changing environment.

- Verifies key patient information (i.e. demographics health care proxy benefit verification and patient preferences for pharmacy facilities VNA etc.) Maintains knowledge and reference materials on key resources available to patients and patients caregivers across the continuum

- Acts as a knowledge resource for post-acute care resources included but not limited to insurance requirements facility attributes contact information etc.

Identifies and refers patients to community services (i.e. transportation food programs day programs and financial programs)

- Communicates consults and collaborates with a wide range of agencies and ambulatory practices under the direction of the care team

Private care options

Working Conditions:

Works in a busy and at times stressful hospital/office environment. Must be able to work well and independently in a multi-disciplinary group. Must be flexible to meet the needs of the organization (work hours work location job tasks remote vs. on-site etc.)

Hybrid

45 Francis Street

40

Regular

Rotating (United States of America)

Pay Range

$20.43 - $29.21/Hourly

Grade

4

At Mass General Brigham we believe in recognizing and rewarding the unique value each team member brings to our organization. Our approach to determining base pay is comprehensive and any offer extended will take into account your skills relevant experience if applicable education certifications and other essential factors. The base pay information provided offers an estimate based on the minimum job qualifications; however it does not encompass all elements contributing to your total compensation addition to competitive base pay we offer comprehensive benefits career advancement opportunities differentials premiums and bonuses as applicable and recognition programs designed to celebrate your contributions and support your professional growth. We invite you to apply and our Talent Acquisition team will provide an overview of your potential compensation and benefits package.

2200 The Brigham and Womens Hospital Inc. is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race color religious creed national origin sex age gender identity disability sexual orientation military service genetic information and/or other status protected under law. We will ensure that all individuals with a disability are provided a reasonable accommodation to participate in the job application or interview process to perform essential job functions and to receive other benefits and privileges of employment. To ensure reasonable accommodation for individuals protected by Section 503 of the Rehabilitation Act of 1973 the Vietnam Veterans Readjustment Act of 1974 and Title I of the Americans with Disabilities Act of 1990 applicants who require accommodation in the job application process may contact Human Resources at .

Mass General Brigham Competency Framework