BFT Aspire Camp Staff - Transition Specialist

Site: The General Hospital Corporation

 

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.

 

 

Job Summary

Aspire is a program of Mass General Brigham that serves teens and young adults with social cognition challenges, including Asperger’s Syndrome, High-Cognitive Autism, Nonverbal Learning Disorder, and autism spectrum disorder that focuses on helping teens develop increased self-awareness, social competency, and stress management skills.

 

Qualifications

Responsible for coordinating the transfer of patients between different levels of care, such as from the hospital to a skilled
nursing facility, home health agency, or outpatient care by working collaboratively with healthcare teams, patients, families, and external
providers to ensure the continuity of care and facilitate successful transitions.

Collaborate with the healthcare team to develop comprehensive care transition plans for patients, taking into account their medical, social, and emotional needs.

Conduct thorough assessments of patients' physical, psychological, and social conditions to determine the most appropriate post-discharge
care setting.

Work closely with healthcare providers to plan and coordinate the timely and safe discharge of patients, ensuring that necessary services
and resources are in place.

Identify and connect patients with appropriate community resources, home health services, durable medical equipment, and other support
services to facilitate a smooth transition from hospital to post-acute care.

Provide patients and their families with education about their medical conditions, medications, self-care techniques, and follow-up care
instructions to promote better health outcomes after discharge.

Document all care coordination activities, assessments, and interventions accurately in the patient's electronic health record (EHR) to
ensure continuity of care and compliance with regulatory requirements.

Advocate for patients' needs during the discharge process, ensuring that they have access to appropriate care and support services upon
leaving the hospital.

Education: bachelor's degree Nursing required

Nursing Experience: 2-3 years required, and Care Coordination/Case Management Experience 1-2 years preferred

Knowledge, Skills and Abilities:

Familiarity with healthcare systems, post-acute care services, and community resources that support care transitions.
Understanding of healthcare regulations and guidelines related to care coordination.

Excellent communication and interpersonal skills to effectively interact with patients, families, healthcare teams, and external providers.

Strong critical thinking and problem-solving abilities to assess complex patient situations and develop appropriate care plans.

Ability to prioritize tasks and manage time effectively in a fast-paced hospital environment.

 

Additional Job Details (if applicable)

Physical Requirements

• Standing (67-100%)
• Walking (67-100%)
• Sitting Constantly (67-100%)
• Lifting Occasionally (3-33%) 20lbs - 35lbs
• Carrying Occasionally (3-33%) 20lbs - 35lbs
• Gross Manipulation (Handling) Constantly (67-100%)
• Fine Manipulation (Fingering) Frequently (34-66%)
• Feeling Constantly (67-100%)
• Vision - Far Constantly (67-100%)
• Vision - Near Constantly (67-100%)
• Talking Constantly (67-100%)
• Hearing Constantly (67-100%)

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Remote Type

Onsite

 

Work Location

399 Revolution Drive

 

Scheduled Weekly Hours

0

 

Employee Type

Temporary

 

Work Shift

Day (United States of America)

 

Pay Range

$17.36 - $23.80/Hourly

 

Grade

2

 

At Mass General Brigham, we believe in recognizing and rewarding the unique value each team member brings to our organization. Our approach to determining base pay is comprehensive, and any offer extended will take into account your skills, relevant experience if applicable, education, certifications and other essential factors. The base pay information provided offers an estimate b