Brigham & Women's Hospital(BWH)
CARE COORDINATION CARE TRANSITION SPECIALIST
Brigham & Women's Hospital(BWH), Boston, Massachusetts, us, 02298
Overview
CARE COORDINATION CARE TRANSITION SPECIALIST Location: Boston, MA (Mission Hill area), United States Job Type: Full Time Posted: 2025-09-29 Company: Brigham & Women2 Hospital (BWH) Job Description
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 with nurse care coordinators, social workers, physicians, and other care team members. The position advocates for patients and families and supports Brigham Health9;s goal of high-quality care, high customer satisfaction, and optimal resource management. On clinical units, the specialist has direct interaction with patients, families, clinical staff, and internal/external customers. Responsibilities
Provides direct administrative support to the care team, patients, and caregivers related to continuum of care, including post-discharge referrals to internal and external resources (e.g., rehabilitation facilities, home health agencies, hospice, DME providers, and other vendors). Manages 4Next referrals along the continuum of care, coordinating with facilities, agencies, and vendors to promote patient progression and effective transitions of care. Secures DME and oxygen for post-acute needs; maps insurance and geography to identify vendors, assesses benefits, coordinates paperwork (e.g., letters of medical necessity, medical records), and arranges delivery of equipment before or after discharge. Supports medication prior-authorization processes, including form completion, securing medical necessity information, and addressing discharge barriers. Assists with scheduling follow-up appointments (specialty and PCP) as part of post-discharge care planning. Obtains and coordinates outside medical records to inform acute treatment plans; secures patient/family consent and oversees content transfer. Communicates with insurers to expedite or manage authorizations for post-acute services and to query for covered services. Distributes and documents key forms to comply with regulations (e.g., Medicare Important Message, Medicare Outpatient Observation Notice) and prepares Medicare appeal documentation as needed. Arranges patient transportation as directed (including Med Flight, ALS, BLS, Chair Car, Care Van, or vouchers) and submits transportation requests (MassHealth PT-1, The Ride) as applicable. Participates in family meetings and interdisciplinary huddles to provide input related to responsibilities. Accesses the electronic medical record to obtain essential information and documents progress notes and Resource Specialist Quick Notes per department standards. Reseaches and secures out-of-state and in-network VNAs and facilities. Initiates/completes regulatory forms (e.g., MassHealth Long-Term Care, DMH/DDS PASSR) and processes them with the appropriate agencies. Completes administrative documentation under the direction of the care team and escalates barriers to discharge. Collects and verifies key patient information (demographics, health care proxy, benefit verification, and patient preferences for pharmacy, facilities, VNA, etc.). Maintains knowledge of resources available to patients and caregivers across the continuum; acts as a knowledge resource for post-acute care resources, insurance requirements, facility attributes, and contact information. Identifies and refers patients to community services (transportation, food programs, day programs, financial programs) and collaborates with ambulatory practices and agencies. Supports private care options as directed. Qualifications
High School Degree or GED required. Associate degree or Bachelor's Degree preferred. Healthcare experience, preferably in extended care facilities and community agencies, preferred. Preferred experience in hospital discharge planning, long-term care facilities, community health, or utilization review. Bilingual preferred. Skills/ Abilities/ Competencies
Interpersonal skills to interact effectively with staff, patients, families, and community organizations; ability to participate in an interdisciplinary team. Extensive knowledge of regulations, community resources, state and federal systems, medical terminology, and levels of health care. Ability to manage a variable workload with shifting priorities; proactive and independent work style. Basic typing and computer data entry skills; experience with PC software desirable. Flexibility in a dynamic environment; ability to work well independently and in a team. Working Conditions
Busy hospital/office environment; must be able to work independently and in a multi-disciplinary group. Flexibility required. EEO Statement
Brigham and Women2 Hospital is an Affirmative Action 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 status, or other protected status. Reasonable accommodations are provided for applicants with disabilities. Primary Location: MA-Boston-BWH Boston Main Campus. Work Locations: BWH Boston Main Campus, 75 Francis St, Boston 02115. Schedule: Full-time. Standard Hours: 40. Shift: Rotating. Employee Status: Regular. Recruiting Department: BWH Nursing / Patient Care Services. Job Posting: Dec 13, 2025. Closed Date: 2025-10-29.
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CARE COORDINATION CARE TRANSITION SPECIALIST Location: Boston, MA (Mission Hill area), United States Job Type: Full Time Posted: 2025-09-29 Company: Brigham & Women2 Hospital (BWH) Job Description
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 with nurse care coordinators, social workers, physicians, and other care team members. The position advocates for patients and families and supports Brigham Health9;s goal of high-quality care, high customer satisfaction, and optimal resource management. On clinical units, the specialist has direct interaction with patients, families, clinical staff, and internal/external customers. Responsibilities
Provides direct administrative support to the care team, patients, and caregivers related to continuum of care, including post-discharge referrals to internal and external resources (e.g., rehabilitation facilities, home health agencies, hospice, DME providers, and other vendors). Manages 4Next referrals along the continuum of care, coordinating with facilities, agencies, and vendors to promote patient progression and effective transitions of care. Secures DME and oxygen for post-acute needs; maps insurance and geography to identify vendors, assesses benefits, coordinates paperwork (e.g., letters of medical necessity, medical records), and arranges delivery of equipment before or after discharge. Supports medication prior-authorization processes, including form completion, securing medical necessity information, and addressing discharge barriers. Assists with scheduling follow-up appointments (specialty and PCP) as part of post-discharge care planning. Obtains and coordinates outside medical records to inform acute treatment plans; secures patient/family consent and oversees content transfer. Communicates with insurers to expedite or manage authorizations for post-acute services and to query for covered services. Distributes and documents key forms to comply with regulations (e.g., Medicare Important Message, Medicare Outpatient Observation Notice) and prepares Medicare appeal documentation as needed. Arranges patient transportation as directed (including Med Flight, ALS, BLS, Chair Car, Care Van, or vouchers) and submits transportation requests (MassHealth PT-1, The Ride) as applicable. Participates in family meetings and interdisciplinary huddles to provide input related to responsibilities. Accesses the electronic medical record to obtain essential information and documents progress notes and Resource Specialist Quick Notes per department standards. Reseaches and secures out-of-state and in-network VNAs and facilities. Initiates/completes regulatory forms (e.g., MassHealth Long-Term Care, DMH/DDS PASSR) and processes them with the appropriate agencies. Completes administrative documentation under the direction of the care team and escalates barriers to discharge. Collects and verifies key patient information (demographics, health care proxy, benefit verification, and patient preferences for pharmacy, facilities, VNA, etc.). Maintains knowledge of resources available to patients and caregivers across the continuum; acts as a knowledge resource for post-acute care resources, insurance requirements, facility attributes, and contact information. Identifies and refers patients to community services (transportation, food programs, day programs, financial programs) and collaborates with ambulatory practices and agencies. Supports private care options as directed. Qualifications
High School Degree or GED required. Associate degree or Bachelor's Degree preferred. Healthcare experience, preferably in extended care facilities and community agencies, preferred. Preferred experience in hospital discharge planning, long-term care facilities, community health, or utilization review. Bilingual preferred. Skills/ Abilities/ Competencies
Interpersonal skills to interact effectively with staff, patients, families, and community organizations; ability to participate in an interdisciplinary team. Extensive knowledge of regulations, community resources, state and federal systems, medical terminology, and levels of health care. Ability to manage a variable workload with shifting priorities; proactive and independent work style. Basic typing and computer data entry skills; experience with PC software desirable. Flexibility in a dynamic environment; ability to work well independently and in a team. Working Conditions
Busy hospital/office environment; must be able to work independently and in a multi-disciplinary group. Flexibility required. EEO Statement
Brigham and Women2 Hospital is an Affirmative Action 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 status, or other protected status. Reasonable accommodations are provided for applicants with disabilities. Primary Location: MA-Boston-BWH Boston Main Campus. Work Locations: BWH Boston Main Campus, 75 Francis St, Boston 02115. Schedule: Full-time. Standard Hours: 40. Shift: Rotating. Employee Status: Regular. Recruiting Department: BWH Nursing / Patient Care Services. Job Posting: Dec 13, 2025. Closed Date: 2025-10-29.
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