Serves and protects the hospital community by adhering to professional standards; hospital care policies and procedures; federal, state, and local requirements; and Joint Commission on Accreditation of Healthcare Organizations (JCAHO) standards.
Navigate Epic reports and databases to identify patients for program enrollment.
Identify patient/family education needs and ensure that patient/family members have adequate information to participate in transition planning.
Critically evaluate and analyze physical and psychosocial assessment data.
Interpret screening and selective laboratory/diagnostic tests.
Initiate and maintain communication and collaboration with physicians, social workers, care team leaders, staff nurses, other care‑giving disciplines, and patients/families to develop, implement, and evaluate a transition plan of care for each patient.
Conduct a comprehensive patient/family assessment and transition/home care planning evaluation upon program enrollment to initiate and maintain the patient's transitional plan of care.
Monitor the achievement of clinical outcomes and communicate with inpatient teams, primary and specialty physicians and staff, regional providers, and community resources (Home Health) regarding unanticipated variances.
Assess complexity of care needs and potential/actual issues or gaps in care.
Arrange post‑discharge medical and community referrals for patients with health problems requiring further evaluation and/or additional services.
Advocate for patients and families within the health care system with community providers and across the continuum of care.
Identify, track, and conduct root cause analyses on readmissions to address programmatic and system‑wide improvements.
Work with physicians, providers, researchers, and Post Acute Care leadership to identify broader system issues affecting patient care.
Leadership
Coordinate and facilitate patient progression throughout the continuum. Collaborate with all members of the healthcare team and external customers.
Participate in clinical performance improvement activities to achieve set goals.
Apply advanced critical thinking and conflict resolution skills using creative approaches.
Support Post Acute Care leadership with system‑level quality improvement.
What You’ll Bring
Requirements
Bachelor's Degree or Master's Degree from an accredited program related to licensure.
5+ years of experience, including 2+ years post‑acute care coordination or case management experience.
Preferences
ACMA Certification as a Case Manager.
Additional Knowledge, Skills & Abilities
Ability to establish strong rapport and relationships with patients and staff.
Proficient in Microsoft Office and industry related software programs.
Computer skills in word processing, database management and spreadsheets.
Identify complex problems and review related information to develop and evaluate options and implement solutions.
Ability to maintain client and staff confidentiality.
Schedule and Work Model
Full-time (Monday through Friday, approximately 8:30am‑5pm).
Hybrid: This role is on-site at Newton‑Wellesley Hospital 75‑80% of the time and includes flexibility for either four days onsite and one remote, or five shorter on‑site days (6‑7 hours) with the remainder remote, based on hospital and patient needs.
Mass General Brigham Community Physicians, Inc. is an Equal Opportunity Employer. By embracing diverse skills, perspectives and ideas, we choose to lead. 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.