Care Transition Specialist, Lead - Post Acute Capacity

Job Description - Care Transition Specialist, Lead - Post Acute Capacity (3306013)

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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 analytical, administrative, and escalation duties for MGB Post-Acute Capacity as directed 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.

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.
• 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.
• 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 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.
• Meets expectations related to collection and synthesis of relevant data, communication summaries, and tracking of tasks and related outcomes as directed by department administration.
• Manages ad hoc projects as directed by department administration.
• Facilitates 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

Minimum Requirements :

• Bachelor’s Degree required and health care experience, preferably in extended care facilities and community agencies.
• 3-year 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.
• Extensive knowledge of regulations, community organization, state and federal systems, medical terminology and levels of health care.
• Ability to manage a variable workload with the ability to constantly change priorities.
• Basic typing and / or computer data entry skills, experience with personal computer and software desirable.
• Flexibility 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.

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