Care Transition Specialist II BWH

Care Transition Specialist

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.

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 4
  
  Next 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 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 hospitals 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 Mass Health 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 Mass Health 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.

High School Diploma required with 3‑5 years of healthcare experience.

Bachelor's Degree in Business preferred.

Bachelor's Degree in a related field of study preferred.

Not specified.

Five years of which at least two must be related to healthcare (5‑7 years total).

• Interpersonal skills to interact effectively with various levels of staff, patients, families, and community organizations. Must be able to participate…