Care Transition Specialist, Lead / 40 hour Rotation - BWH Care Coordination - Post Acute Capacity
GENERAL SUMMARY/OVERVIEW
As a member of the Mass General Brigham - Care Continuum Management team, the Care Transition Specialist Lead will routinely perform Care Transition Specialist duties in addition to completing and supporting with analytical, administrative, and escalation duties for MGB Post-Acute Capacity and as directed by department administration. The analytical, administrative, and training duties will be balanced with the Care Transition Specialist duties by department administration. The Care Transition Specialist Lead will work with Case Managers, Social Workers, and other care team staff to ensure that patients receive the resources and services they need to successfully return to a community setting, including home with services (i.e. Visiting Nurse Association) or without services, skilled nursing facility, acute rehab, long term acute care facility or outpatient clinic. The Care Transition Specialist Lead is responsible for managing system referrals, escalations and supporting patient progression. The Care Transition Specialist Lead is responsible for acting as an advocate for patients and patient families and strive to support the hospital's aims for optimal resource management, high customer satisfaction, and high quality care.
Patient Care Management:
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