Job Info
TCM Referral Coordinator - 40 hour Day - BWH Post-Acute Capacity Care Coordination
GENERAL SUMMARY
As a member of the Mass General Brigham - The Transitional Care Manager (TCM) coordinates placement for capacity patients and helps guide them through the transition from one level of care to another. The goal is to optimize patient care transitions thereby reducing unnecessary utilization of services and decrease the risk of readmissions.
The TCM Referral Coordinator is responsible for managing capacity system referrals, escalations and supporting patient progression. The TCM Referral Coordinator 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. In addition, the TCM Referral Coordinator will complete and support analytical, administrative, and escalation duties for MGB Post-Acute Capacity and as directed by department administration. The TCM Referral Coordinator 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.
This position requires a broad knowledge of academic medical centers, community hospitals, post-acute services, clinical systems, electronic medical records (EMRs), and rehabilitative expertise. Additionally, a broad knowledge of clinical care, payer rules including but not limited to Medicare, and health services across the continuum of care are required.
The TCM will demonstrate careful professional and clinical judgement, effective problem-solving skills, critical thinking, excellent organizational and interpersonal skills, flexibility, and the ability to multi-task. In addition to the above, the TCM will stay up to date in matters relating to care coordination, applicable Federal and State regulations, risk management, community resources and other pertinent continuum of care topics.
Patient Care Management:
Assists with MGB Post-Acute Capacity referrals as directed by the Post-Acute Capacity team Conducts a comprehensive assessment of all acute hospital admissions for patients in the targeted population(s). Review of the patient's outpatient and inpatient electronic medical record. including but not limited to H&P, diagnosis and treatment plan, nursing, rehab (PT/OT/Speech) and case management notes. Acts as a consultant to the system hospital community regarding the placement process and access to community resources. Coordinates and expedites final transfer with team to support a smooth transition and assure continuity of care as the patient moves through the continuum. Referral Management: Coordinates long and short term placements to extended care facilities, e.g. rehabs, sub-acute, etc. Facilitate coordination across the continuum and assist with evaluating appropriate post-acute level of care with interdisciplinary team's (acute, post-acute, hospice and palliative care). Plans, when appropriate, a continuation of previous utilization management services and/or agency for continuity of care. Interprets insurance coverage and makes recommendations for short term rehab or non-acute options. Develops relationships and maintains contact with appropriate facilities and resources. Occasionally visits sites.Updates the staff on new facilities, services, and resources; and maintains a library of reference materials. Evaluation: Monitors quality of care in ECF's, home/community agencies and reports findings to the Program Manager. Maintains current information on non-acute provider agencies, including SNF, sub-acute, acute rehab and chronic facilities, including programs, homecare and specialties available. Provides follow-up and ongoing assistance with assessing community and ECF services. Follows up and tracks utilization of referred patients for evaluation purposes and provides feedback to the Program Manager. Participates in relevant planning meetings to provide input into practice and program needs. Performance Improvement: Participates in Capacity Meetings, individual SNF meetings, and program management meetings. Includes contributing to discussions, reviewing data, and focus on improvement efforts per established priorities. Maintains a statistical database on escalations, referrals, admissions and homecare/community agency resources and tracks discharge process utilized by the patient. Maintains contact with State regulatory agencies and non-acute care provider agencies to keep current on the rules and regulations needed to facilitate discharge planning. Analysis, Administrative, and Training Duties: Analyzes operational data to evaluate performance as directed by department administration Supports the documentation of outcomes and ideas generated through task forces and initiatives as it relates to the department's objectives and specifically related to post-acute as directed and overseen by department administration Meet expectations related to collection and synthesis of relevant data, communication summaries, and tracking of tasks and related outcomes as directed by department administration Manage ad hoc projects as directed by department administration Facilitate process and technical training for Care Transition Specialists and other department roles as directed by department administration Working hours:
Tuesday - Saturday
8:00am to 4:30pm or 8:30am to 5pm
Rotating Hours
Hybrid
Qualifications Qualifications
Physical Therapist (PT), Physical Therapist Assistant (PTA), Occupational Therapist (OT), Speech-Language Pathologists (SLP). Graduate of an accredited program related to licensure is required. Bachelor's or master's degree preferred. Minimum 2+ years of experience of acute hospital or post-acute care setting required. Minimum of 2+ years of case management, utilization review and discharge planning experience preferred. Evidence of continued education and professional development. Experience with basic Microsoft Excel, PowerPoint, and Word preferred. SKILLS/ ABILITIES/ COMPETENCIES REQUIRED
Strong assessment, critical thinking, and problem-solving skills. Strong interpersonal skills including excellent oral, written, and telephonic skills and abilities. Ability to work independently with minimal supervision. Ability to work in an interdisciplinary team-based environment. Goal oriented and accountable. Demonstrated organizational skills and an ability to manage routine work, triage and reset priorities as needed. Must be able to work in a fast-paced complex setting and demonstrate performance agility in a continuously changing environment. Demonstrates appropriate communication skills for the patient population served. Computer skills with the ability to quickly demonstrate competency in various software applications. Strong data analytic skills and interest in tying data to clinical outcomes. Flexibility with tasks and assignments as program needs dictate. Examples include assisting colleagues and providing coverage during vacations/unexpected illness/holiday time. WORKING CONDITIONS:
Flexibility to work and travel to a variety of locations as well as remotely. On-site settings include acute hospital, Assembly Row, and post-acute skilled nursing facility settings. Hours and work schedule will be flexible to meet the needs of patients, families, and facility staff but will generally follow a Tuesday-Saturday eight-hour work schedule. Requires flexibility to support Holidays. EEO Statement Brigham and Women's Hospital is an Affirmative Action 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.
