Site: The Brigham and Women's Hospital, Inc.

Mass General Brigham relies on a wide range of professionals, including doctors, nurses, business people, tech experts, researchers, and systems analysts to advance our mission. As a not-for-profit, we support patient care, research, teaching, and community service, striving to provide exceptional care. We believe that high-performing teams drive groundbreaking medical discoveries and invite all applicants to join us and experience what it means to be part of Mass General Brigham.

shift: 40hr rotation

Job Summary

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.

1. Provides direct administrative support to the care team, patients, and patients’ caregivers related to continuum of care:
   a. 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
   b. 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.
   c. 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.
   d. 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.
   e. Schedules post-discharge appointments for OB/NICU only.
   f. 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
   g. Communicates with insurance companies to expedite and/or manage delays with authorization for DME or query for covered services
   h. 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.
   i. Documents all tasks in EPIC, (in-progress, follow-up, completed, etc.)
   j. 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
   k. Submits longitudinal transport requests, including Mass Health PT-1 and The Ride applications for patients meeting requirements
   l. Participates in interdisciplinary huddles to gather information and provide updates to patient’s care team
   m. Participates in family/team meetings to solicit and provide input related to their responsibilities
   n. 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
   o. Researches and secures out of state and in-network VNAs and facilities, as needed
   p. Gathers and submits regulatory documentation, such as the Mass Health Long-Term Care paperwork, to the appropriate agencies
   q. Escalates barriers to discharge to appropriate leadership
   r.

Completes HCP and submits to EPIC for upload in EMR:

s. Other duties, as assigned by Resource Center Leadership

Qualifications

Education:

High School Diploma required with 3-5 years of healthcare experience

Bachelor's Degree Business preferred:

Bachelor's Degree Related Field of Study preferred:

Licenses and Credentials:

Experience:

Five years of which two must be related to healthcare 5-7 years

Skills/Abilities:

• 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.

Additional Job Details (if applicable)

• 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

Working Conditions:

Works in a busy and, at times, stressful hospital/office environment. Must be able to work well and independently in a multi-disciplinary group. Must be flexible to meet the needs of the organization (work hours, work location, job tasks, remote vs. on-site etc.)

Remote Type

Hybrid

Work Location

45 Francis Street

Scheduled Weekly Hours

40

Employee Type

Regular

Work Shift

Rotating (United States of America)

Pay Range

$20.84 - $29.79/Hourly

Grade

4

At Mass General Brigham, we believe in recognizing and rewarding the unique value each team member brings to our organization. Our approach to determining base pay is comprehensive, and any offer extended will take into account your skills, relevant experience if applicable, education, certifications and other essential factors. The base pay information provided offers an estimate based on the minimum job qualifications; however, it does not encompass all elements contributing to your total compensation package. In addition to competitive base pay, we offer comprehensive benefits, career advancement opportunities, differentials, premiums and bonuses as applicable and recognition programs designed to celebrate your contributions and support your professional growth. We invite you to apply, and our Talent Acquisition team will provide an overview of your potential compensation and benefits package.

EEO Statement:

2200 The Brigham and Women's Hospital, Inc. is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religious creed, national origin, sex, age, gender identity, disability, sexual orientation, military service, genetic information, and/or other status protected under law. We will ensure that all individuals with a disability are provided a reasonable accommodation to participate in the job application or interview process, to perform essential job functions, and to receive other benefits and privileges of employment. To ensure reasonable accommodation for individuals protected by Section 503 of the Rehabilitation Act of 1973, the Vietnam Veteran’s Readjustment Act of 1974, and Title I of the Americans with Disabilities Act of 1990, applicants who require accommodation in the job application process may contact Human Resources at (857)-282-7642.

Mass General Brigham Competency Framework

At Mass General Brigham, our competency framework defines what effective leadership “looks like” by specifying which behaviors are most critical for successful performance at each job level. The framework is comprised of ten competencies (half People-Focused, half Performance-Focused) and are defined by observable and measurable skills and behaviors that contribute to workplace effectiveness and career success. These competencies are used to evaluate performance, make hiring decisions, identify development needs, mobilize employees across our system, and establish a strong talent pipeline.