CARE COORDINATION CARE TRANSITION SPECIALIST II

GENERAL SUMMARY/OVERVIEW

CARE TRANSITION SPECIALIST II / 40 HOURS / ROTATING - BWH CARE COORDINATION

The Care Transition Specialist works collaboratively with Care Coordination to complete administrative responsibilities related to care progression and care transitions along the continuum of care. They work collaboratively with nurse care coordinators, social workers, physicians, and other care team members. The Care Transition Specialist is responsible for acting as an advocate for patients and patient families and strives to support Brigham Health’s aim for high quality care, high customer satisfaction, and optimal resource management. The person in this position will spend time on the clinical units and have direct interaction with patients and their families, clinical and ancillary hospital staff, and other internal and external customers.

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. Assists with the completion of patient follow-up appointments (specialty and PCP) for follow-up care needs

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 post-acute care and services or query for covered services

h. 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.

i. 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 Vouchers

j. Submission of longitudinal transport requests, including MassHealth PT-1 and The Ride Applications for patients meeting requirements

k. Participates in family meetings and interdisciplinary huddles to solicit and provide input related to their responsibilities

l. Accesses and navigates the electronic medical record to obtain essential information, documents progress notes and Resource Specialist Quick Notes as per department standards.

m. Researches and secures out of state and in-network VNAs and facilities

n. Initiates and/or completes regulatory and other forms, such as MassHealth Long-Term Care and DMH/DDS PASSR forms and processes the completed forms with the appropriate agencies.

o. Completes administrative documentation under the direction of the care team

p. Escalates barriers to discharge

2. Collects, confirms and verifies key patient information (i.e., demographics, health care proxy, benefit verification, and patient preferences for pharmacy, facilities, VNA, etc)

3. Maintains knowledge and reference materials on key resources available to patients and patients’ caregivers across the continuum

a. Acts as a knowledge resource for post-acute care resources, included but not limited to, insurance requirements, facility attributes, contact information, etc.

b. Identifies and refers patients to community services (i.e. transportation, food programs, day programs, and financial programs)

c. Communicates, consults and collaborates with a wide range of agencies and ambulatory practices under the direction of the care team

d. Private care options

Working hours:

8:00am - 4:30pm
8:30am - 5:00pm
Weekend rotation required

1. High School Degree or GED required.

2. Associate degree or Bachelor’s Degree preferred

3. Health care experience, preferably in extended care facilities and community agencies, preferred

4. Preferred experience in hospital discharge planning, long term care facility, community health or utilization review preferred

5. Bilingual preferred

SKILLS/ ABILITIES/ COMPETENCIES REQUIRED:

WORKING CONDITIONS:
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.
SUPERVISORY RESPONSIBILITY:
None
FISCAL RESPONSIBILITY:
None