Care Transition Specialist II

4 weeks ago

Boston, Massachusetts, United States Brigham & Women's Hospital(BWH) Full time
Care Transition Specialist II Job Description

The Care Transition Specialist II works collaboratively with the Care Coordination team to complete administrative responsibilities related to care progression and care transitions along the continuum of care.

They work closely with nurse care coordinators, social workers, physicians, and other care team members to ensure seamless transitions for patients and their families.

The Care Transition Specialist II is responsible for acting as an advocate for patients and patient families, supporting Brigham Health's aim for high-quality care, high customer satisfaction, and optimal resource management.

Key Responsibilities:

  • Supports the administrative tasks and communication related to post-discharge care, including referrals to internal and external resources.
  • Actively manages 4Next referrals along the continuum of care, communicating with facilities, agencies, and vendors to promote patient progression and effective transitions of care.
  • Secures durable medical equipment (DME) and oxygen for post-acute needs, mapping insurance and geography to identify appropriate vendors and assessing insurance benefits.
  • Coordinates the necessary paperwork with external vendors and the medical team for approval of equipment, including letters of medical necessity, medical record documentation, and prescriptions.
  • Arranges for and tracks the delivery of equipment prior to or post-discharge.
  • Performs administrative tasks to support medication prior-authorization, including completion of forms and securing medical necessity information.
  • Assists with the completion of patient follow-up appointments for specialty and primary care needs.
  • Secures medical records from outside hospitals, including outreach to outside hospitals, completion of forms, and securing consent from patients or families.
  • Communicates with insurance companies to expedite and/or manage delays with authorization for post-acute care and services.
  • Distributes and documents key forms and documents to comply with regulations, including Medicare Important Message and Medicare Outpatient Observation Notice.
  • 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.
  • Submits 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.

Requirements:

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

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