Care Transition Specialist, Lead
2 weeks ago
Care Transition Specialist, Lead / 40 hour Rotation - BWH Care Coordination - Post Acute Capacity
GENERAL SUMMARY/OVERVIEW
As a member of the Mass General Brigham - Care Continuum Management team, the Care Transition Specialist Lead will routinely perform Care Transition Specialist duties in addition to completing and supporting with analytical, administrative, and escalation duties for MGB Post-Acute Capacity and as directed by department administration. The analytical, administrative, and training duties will be balanced with the Care Transition Specialist duties by department administration. The Care Transition Specialist Lead will work with Case Managers, Social Workers, and other care team staff to ensure that patients receive the resources and services they need to successfully return to a community setting, including home with services (i.e. Visiting Nurse Association) or without services, skilled nursing facility, acute rehab, long term acute care facility or outpatient clinic. The Care Transition Specialist Lead is responsible for managing system referrals, escalations and supporting patient progression. The Care Transition Specialist Lead is responsible for acting as an advocate for patients and patient families and strive to support the hospital's aims for optimal resource management, high customer satisfaction, and high quality care.
Patient Care Management:
- Assists with MGB Post-Acute Capacity referrals as directed by the Post-Acute Capacity team
- Proactively facilitates referrals across Mass General Brigham, ordering of equipment (e.g. DME) and medication, completion of forms, and placement from inpatient and outpatient settings.
- Acts as a consultant to the hospital community, patients and families regarding the placement process and access to community resources.
- Establishes homecare plan in conjunction with the CCM and documents the plan and progress in the medical record, including assistance with obtaining medications or DME needed at discharge.
- Coordinates and expedites final transfer with staff, patient, family and facility.
- Updates the staff on new facilities, services, and resources; and maintains a library of reference materials.
Referral Management:
- Coordinates long and short term placements to extended care facilities, e.g. rehabs, sub-acute, etc. Documents discharge plan in electronic referral system or via fax, and monitors, and manages follow-up or escalates, as needed.
- Actively communicates, consults and collaborates with a wide range of social agencies, clinics, schools and courts.
- Plans, when appropriate, a continuation of previous utilization management services and/or agency for continuity of care.
- Interprets insurance coverage and makes recommendations for short term rehab or non-acute options.
- Develops relationships and maintains contact with appropriate facilities and resources. Occasionally visits sites.
Evaluation:
- Monitors quality of care in ECF's, home/community agencies and reports findings to the Program Manager.
- Maintains current information on non-acute provider agencies, including SNF, sub-acute, acute rehab and chronic facilities, including programs, homecare and specialties available. Acts as a resource to staff, patients and families concerning this information.
- Provides follow-up and ongoing assistance with assessing community and ECF services. Follows up and tracks utilization of referred patients for evaluation purposes and provides feedback to the Program Manager.
- Participates in relevant planning meetings to provide input into practice and program needs.
Performance Improvement:
- Maintains a statistical data base on escalations, referrals, admissions and homecare/community agency resources and tracks discharge process utilized by the patient.
- Participates in the development and monitoring of performance standards for extended care facilities and homecare/community agencies. Maintains documentation to support findings.
- Maintains contact with State regulatory agencies and non-acute care provider agencies to keep current on the rules and regulations needed to facilitate discharge planning.
Analysis, Administrative, and Training Duties:
- Analyzes operational data to evaluate performance as directed by department administration
- Supports the documentation of outcomes and ideas generated through task forces and initiatives as it relates to the department's objectives and specifically related to Post-Acute as directed and overseen by department administration
- Meet expectations related to collection and synthesis of relevant data, communication summaries, and tracking of tasks and related outcomes as directed by department administration
- Manage ad hoc projects as directed by department administration
- Facilitate process and technical training for Care Transition Specialists and other department roles as directed by department administration
Working hours:
Tuesday - Saturday
8:00am to 4:30pm or 8:30am to 5pm
Rotating Hours
Hybrid
Qualifications- Bachelor's Degree required and health care experience, preferably in extended care facilities and community agencies.
- Required, 3-yr experience in hospital discharge planning, long term care facility, community health or utilization review.
SKILLS/ ABILITIES/ COMPETENCIES REQUIRED
- 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.
Brigham and Women's Hospital is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, sex, color, religion, national origin, sexual orientation, protected veteran status, or on the basis of disability.
Primary Location: MA-Boston-BWH Boston Main Campus Work Locations: BWH Boston Main Campus 75 Francis St Boston 02115 Job: Social Services/Mental Health - Other Organization: Brigham & Women's Hospital(BWH) Schedule: Full-time Standard Hours: 40 Shift: Rotating Posted Shift Description: Tuesday - Saturday8am to 4:30pm or 8:30am to 5pm Employee Status: Regular Recruiting Department: BWH Nursing / Patient Care Services Job Posting: May 6, 2024
-
Care Transition Specialist II
4 weeks ago
Boston, United States Brigham & Women's Hospital(BWH) Full timeCare Transition Specialist II - 40 hour Rotating - BWH CCM Care Coordination GENERAL SUMMARY/OVERVIEW 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,...
-
Care Transitions Coordinator
6 days ago
Boston, Massachusetts, United States Beth Israel Deaconess Medical Center Full timeAbout the RoleWe are seeking a highly skilled and detail-oriented Care Transitions Coordinator to join our team at Beth Israel Deaconess Medical Center. As a key member of our care transitions team, you will play a critical role in ensuring seamless transitions for our patients from hospital to home or other post-acute care settings.Key...
-
Care Transitions Coordinator
1 week ago
Boston, Massachusetts, United States Beth Israel Deaconess Medical Center Full timeAbout the RoleWe are seeking a highly skilled and detail-oriented Care Transitions Coordinator to join our team at Beth Israel Deaconess Medical Center. As a key member of our care transitions team, you will play a critical role in ensuring seamless transitions for our patients from hospital to home or other post-acute care settings.Key...
-
Care Transitions Coordinator
1 week ago
Boston, Massachusetts, United States Beth Israel Deaconess Medical Center Full timeAbout the RoleWe are seeking a highly skilled and detail-oriented Care Transitions Coordinator to join our team at Beth Israel Deaconess Medical Center. As a key member of our care transitions team, you will play a critical role in ensuring seamless transitions for our patients from hospital to home or other post-acute care settings.Key...
-
Care Transitions Coordinator
6 days ago
Boston, Massachusetts, United States Beth Israel Deaconess Medical Center Full timeAbout the RoleWe are seeking a highly skilled and detail-oriented Care Transitions Coordinator to join our team at Beth Israel Deaconess Medical Center. As a key member of our care transitions team, you will play a critical role in ensuring seamless transitions for our patients from hospital to home or other post-acute care settings.Key...
-
Inpatient Care Transition Nurse
6 days ago
Boston, Massachusetts, United States Tufts Medical Center Full timeJob SummaryWe are seeking a highly skilled Cardiology Clinic Nurse to join our team at Tufts Medical Center. As a key member of our care team, you will be responsible for coordinating the transition of care from one healthcare setting to another, ensuring seamless transitions for our patients.Key ResponsibilitiesRisk Assessment and Management: Perform risk...
-
Care Transitions Coordinator
1 week ago
Boston, Massachusetts, United States Beth Israel Deaconess Medical Center Full timeAbout the RoleWe are seeking a highly skilled and detail-oriented Care Transitions Coordinator to join our team at Beth Israel Deaconess Medical Center. As a key member of our care transitions team, you will play a critical role in ensuring seamless transitions for our patients from hospital to home or other post-acute care settings.Key...
-
Clinical Care Transition Educator
2 months ago
Boston, United States Option Care Enterprises, Inc. Full timeThe Clinical Transition Educator is responsible for providing clinical education and training to ensure successful transition of patients to an Option Care Health care delivery model. The Clinical Transition Educator will also be responsible for par Registered Nurse, Clinical, Educator, Registered, Nurse, Microsoft, Healthcare
-
Care Transitions Coordinator
1 week ago
Boston, Massachusetts, United States Beth Israel Deaconess Medical Center Full timeAbout the RoleWe are seeking a highly skilled and detail-oriented Care Transitions Coordinator to join our team at Beth Israel Deaconess Medical Center. As a key member of our care transitions team, you will play a critical role in ensuring seamless transitions for our patients from hospital to home or other post-acute care settings.Key...
-
Clinical Care Transition Educator
2 months ago
Boston, United States Option Care Health Full timeExtraordinary Careers. Endless Possibilities. With the nation’s largest home infusion provider, there is no limit to the growth of your career. Option Care Health, Inc. is the largest independent home and alternate site infusion services provider in the United States. With over 6,000 team members including 2,900 clinicians, we work compassionately to...
-
Heart Failure Transition Specialist
6 days ago
Boston, Massachusetts, United States Tufts Medical Center Full timeJob OverviewThis position plays a critical role in coordinating the transition of care for patients with heart failure, ensuring a seamless transition from one healthcare setting to another. The ideal candidate will have a strong background in nursing and experience working with patients with heart failure.Key ResponsibilitiesInpatient CareIdentify eligible...
-
Critical Care Nurse Specialist
1 day ago
Boston, Massachusetts, United States Tufts Medical Center Full timeAbout the RoleWe are seeking a highly skilled and experienced Critical Care Nurse Specialist to join our team at Tufts Medical Center. As a Critical Care Nurse Specialist, you will be responsible for providing high-quality patient care in our Cardiac ICU, working closely with our interdisciplinary team to ensure the best possible outcomes for our...
-
Senior Care Lead Specialist
1 week ago
Boston, Massachusetts, United States Babette Home Care Full timeLead Caregiver Position:The Lead Caregiver will serve in a multifaceted role, providing essential support to both the administrative team and clients, as well as assisting caregivers with their daily operational tasks. Responsibilities will include welcoming new clients and caregivers during introductions, filling in for caregivers during their absences,...
-
Senior Care Lead Specialist
2 weeks ago
Boston, Massachusetts, United States Babette Home Care Full timeLead Caregiver Position:The Lead Caregiver will serve in a dual capacity, providing essential support to both the administrative team and the caregiving staff, as well as assisting clients with their daily operational requirements. Responsibilities will include welcoming new clients and caregivers during introductions, filling in for caregivers during their...
-
Patient Transition Facilitator/Coordinator
3 weeks ago
Boston, United States Tufts Medical Center Full timeHours: 40 hours per week; Monday through Friday from 8:00 AM to 4:30 PM Location: 100% onsite at 800 Washington St. Boston, MA - Tufts Medical Center Job Overview This position assists with throughput by eliminating the restrictions of attempting to schedule follow-up at time of discharge. Supports primary and specialty care scheduling for discharged...
-
Transitions of Care RN
5 days ago
Boston, United States Boston Medical Center Full timePOSITION SUMMARY: The Transitions of Care Nurse Complex Care Manager works with relevant stakeholders to identify and engage patients in care management with a focus on enhancing patient health and well-being, increasing patient satisfaction, and reducing healthcare costs. The nurse works with inpatient, complex care management, and community-based staff to...
-
Cardiology Clinic Nurse Specialist
2 days ago
Boston, Massachusetts, United States Tufts Medical Center Full timeJob SummaryWe are seeking a highly skilled Cardiology Clinic Nurse Specialist to join our team at Tufts Medical Center. The successful candidate will be responsible for coordinating the transition of care from one healthcare setting to another, ensuring seamless transitions for our patients.Key ResponsibilitiesTransition of Care: Collaborate with the...
-
Rail & Transit Senior Engineer - 3532
6 days ago
Boston, Massachusetts, United States STV Full timeAbout STVAt STV, we are a leading industry player that not only tackles world-class projects but also develops employee skills, recognizes achievements, and offers opportunities for advancement. Our goal is to provide a rewarding position for individuals who are passionate about their work and want to grow with a reputable company.Our Commitment to Employee...
-
Rail & Transit Senior Engineer - 3532
3 months ago
Boston, United States STV Full timeDescription Rail & Transit Senior Engineer Build Your Career at STV At STV, we not only tackle world-class projects, we also develop employee skills, recognize achievements and offer opportunities for advancement. So, if you’re looking for a rewarding position working for an industry leader, then STV is the place for you. Grow at STV ...
-
Social Worker Lead/ SUD Bridge Clinic
3 weeks ago
Boston, United States Massachusetts General Hospital Full timeDescription Substance Use Disorder / LICSW Behavioral Health Lead/ 40 Hours Full Time/ MGH- Bridge Clinic Ask about Sign on Bonus! Available for eligible non-MGB employees. Generous and broad benefits include: multiple medical plans, dental, matched 403B, cash balance/pension, tuition reimbursement, transit subsidy, Paid Time Off and much more! GENERAL...