Site: Mass General Brigham Community Physicians, 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.
Opportunity The Transitional Care Manager position is based at Newton-Wellesley Hospital and is responsible for managing a patient's successful transition from hospital to home. The role is accountable for developing, implementing, and evaluating comprehensive transitional care interventions for high-risk medical, surgical, and/or trauma patients at MGB. Responsibilities include managing the post-acute care of high-risk patients at risk for poor health outcomes, frequent emergency room visits, and hospital readmissions, and working with complex and varied patients and situations.
Job Summary Primary Responsibilities 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.
Navigates Epic reports and databases to identify patients for program enrollment.
Identifies patient/family education needs and ensures that patient/family members have adequate information to participate in transition planning.
Critically evaluates and analyzes physical and psychosocial assessment data.
Interprets screening and selective laboratory/diagnostic tests.
Initiates and maintains communication and collaboration with physicians, social workers, care team leaders, staff nurses, other caregiving disciplines, and patients/families to develop, implement, and evaluate a transition plan of care for each patient.
Conducts 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.
Monitors the achievement of clinical outcomes and communicates with inpatient teams, primary and specialty physicians and staff, regional providers, and community resources (Home Health) regarding unanticipated variances.
Assesses complexity of care needs and potential/actual issues or gaps in care.
Arranges post-discharge medical and community referrals for patients with health problems requiring further evaluation and/or additional services.
Advocates for patients and families within the health care system with community providers and across the continuum of care.
Identifies, tracks, and conducts root cause analyses on readmissions to address programmatic and system-wide improvements.
Works with physicians, providers, researchers, and Post Acute Care leadership to identify broader system issues affecting patient care.
Leadership Coordinates and facilitates patient progression throughout the continuum. Collaborates with all members of the healthcare team and external customers.
Participates in clinical performance improvement activities to achieve set goals.
Applies advanced critical thinking and conflict resolution skills using creative approaches.
Supports Post Acute Care leadership with system-level quality improvement.
Qualifications Requirements Bachelor's Degree or Master's Degree from an accredited program related to licensure.
Occupational Therapist Licensure, Physical Therapist Licensure or Physical Therapist Assistant 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.
Identifying complex problems and reviewing 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.
Remote Type Hybrid
Work Location 2014 Washington Street
Scheduled Weekly Hours 40
Employee Type Regular
Work Shift Day (United States of America)
Pay Range $58,656.00 - $142,448.80 per year
Grade 98TEMP
Compensation Overview At Mass General Brigham, we believe in recognizing and rewarding the unique value each team member brings. Our approach to determining base pay is comprehensive; any offer will take into account your skills, relevant experience, education, certifications, and other essential factors. The figure provided is an estimate based on minimum qualifications and does not encompass all elements contributing to total compensation. In addition to competitive base pay, we offer comprehensive benefits, career advancement opportunities, differentials, premiums and bonuses, and recognition programs designed to celebrate your contributions and support your professional growth.
EEO Statement Mass General Brigham Community Physicians, 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, 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 under 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 may contact Human Resources at (857)‑282‑7642.
Mass General Brigham Competency Framework Our competency framework defines what effective leadership looks like by specifying the behaviors most critical for successful performance at each job level. The framework includes ten competencies—half People‑Focused, half Performance‑Focused—and is used to evaluate performance, make hiring decisions, identify development needs, mobilize employees across our system, and establish a strong talent pipeline.