Care Transition Specialist II BWH

Mass General Brigham•Boston, MA

12d•$21 - $30•Hybrid

About The Position

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 Brigham’s 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.

Requirements

High School Diploma required with 3-5 years of healthcare experience
Five years of which two must be related to healthcare 5-7 years
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.

Nice To Haves

Bachelor's Degree Business preferred
Bachelor's Degree Related Field of Study preferred

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.
Schedules post-discharge appointments for OB/NICU only.
Secures 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
Communicates with insurance companies to expedite and/or manage delays with authorization for DME or query for covered services
Distributes 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.
Documents all tasks in EPIC, (in-progress, follow-up, completed, etc.)
Coordinates all forms of patient transportation as directed by the care team, including Med Flight, ambulance (ALS, BLS), Chair Car, Circulation, and Boston Cab vouchers
Submits longitudinal transport requests, including MassHealth PT-1 and The Ride applications for patients meeting requirements
Participates in interdisciplinary huddles to gather information and provide updates to patient’s care team
Participates in family/team meetings to solicit and provide input related to their responsibilities
Accesses and navigates the electronic medical record to obtain essential information, document progress notes and update the Resource Specialist Quick Notes as per department standards
Researches and secures out of state and in-network VNAs and facilities, as needed
Gathers and submits regulatory documentation, such as the MassHealth Long-Term Care paperwork, to the appropriate agencies
Escalates barriers to discharge to appropriate leadership
Completes HCP and submits to EPIC for upload in EMR
Other duties, as assigned by Resource Center Leadership
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