The Care Transition Specialist completes administrative responsibilities related to care progression and care transitions along the continuum of care. They work collaboratively with nurse care coordinators, social workers, physicians, and other care team members. The Care Transition Specialist is responsible for acting as an advocate for patients and patient families and strives to support Newton Wellesley Hospital's aim for high quality care, high customer satisfaction, and optimal resource management.

1. Provides direct administrative support to the care team, patients, and patients' caregivers:

a. Support the administrative tasks and communication related to post discharge care (e.g., the 4Next

process, faxing to long term care facilities, follow-up appointments, etc.).

b. Performs administrative tasks to support the ordering of equipment, completion of forms, and

medication authorizations.

c. Distributes key forms and documents to comply with regulations (e.g., MOON, IM, etc.).

d. Arranges all types of patient transportation under the direction of the care team.

e. May participate in family meetings and interdisciplinary huddles to solicit and provide input related

to their responsibilities.

f. Completes administrative documentation under the direction of the care team.

2. Collects, confirms, and verifies key patient information (i.e., demographics, health care proxy, benefit

verification, and patient preferences for pharmacy, VNA, etc.)

3. Maintains knowledge and reference materials on key resources available to patients and patients' caregivers

across the continuum:

a. Acts as a knowledge resource for post-acute care resources, included but not limited to, insurance

requirements, facility attributes, contact information, etc.

b. Identifies and refers patients to community services (i.e., transportation, food programs, day

programs, and financial programs)

c. Communicates, consults, and collaborates with a wide range of social agencies, clinics, schools, and

courts under the direction of the care team

Education:

1. High School Degree or GED required.

2. Associate's Degree or Bachelor's Degree preferred and health care experience, preferably in extended care facilities and community agencies.

3. Preferred experience in hospital discharge planning, long term care facility, community health or utilization review.

Job Knowledge and Skills:

1. Interpersonal skills to interact effectively with various levels of staff, patients, families and community organizations.

Must be able to participate effectively in an interdisciplinary team setting.

2. Extensive knowledge of regulations, community organization, state and federal systems, medical terminology and

levels of health care.

3. Must be able to manage a variable workload with the ability to constantly change priorities. Requires ability to work

proactively and independently.

4. Requires basic typing and/or computer data entry skills, experience with personal computer and software desirable.

5. Must be very flexible in a constantly changing environment.