Healthcare Continuum Coordinator
7 days ago
Brigham & Women's Hospital (BWH) seeks a skilled Care Transition Specialist II to join our care coordination team. This role plays a vital part in ensuring seamless transitions for patients across the healthcare continuum.
Job Overview:The Care Transition Specialist II is responsible for providing administrative support to the care team, patients, and their families. They will work collaboratively with nurse care coordinators, social workers, physicians, and other care team members to ensure effective transitions of care.
Responsibilities:- Provides direct administrative support to the care team, patients, and patients' caregivers related to continuum of care:
- 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;
- 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;
- 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;
- 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;
- Assists with the completion of patient follow-up appointments (specialty and PCP) for follow-up care needs;
- Secures medical records from outside hospitals 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;
- Communicates with insurance companies to expedite and/or manage delays with authorization for post-acute care and services or query for covered service;
- 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;
- 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 Voucher;
- Submission of longitudinal transport requests, including MassHealth PT-1 and The Ride Applications for patients meeting requirements;
- Participates in family meetings and interdisciplinary huddles to solicit and provide input related to their responsibilities;
- Accesses and navigates the electronic medical record to obtain essential information, documents progress notes and Resource Specialist Quick Notes as per department standards;
- Researches and secures out of state and in-network VNAs and facilities;
- Initiates and/or completes regulatory and other forms, such as MassHealth Long-Term Care and DMH/DDS PASRR forms and processes the completed forms with the appropriate agencies;
- Completes administrative documentation under the direction of the care team;
- Escalates barriers to discharge;
To be considered for this role, you should have:
- An Associate degree or Bachelor's Degree preferred;
- Healthcare 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;
- 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 healthcare;
- 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;
This role works in a busy and, at times, stressful hospital/office environment. Must be able to work well independently and in a multi-disciplinary group. Must be flexible.
Salary:$65,000 - $85,000 per year, depending on experience.
© Brigham and Women's Hospital
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