Transitional Care Manager
 North Shore Physicians Group, Inc. | |
 United States, Massachusetts, Salem | |
| 81 Highland Avenue (Show on map) | |
 Sep 24, 2025 | |
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The Transitional Care Manager is responsible for managing a patient's successful transition from hospital to home and is accountable for developing, implementing, and evaluating comprehensive transitional care interventions for high risk medical, surgical, and/or trauma patients at MGB. They are responsible for managing the post-acute care of high-risk patients that are at risk for poor health outcomes, frequent emergency room visits, and hospital readmissions and working with complex and varied patients and situations.
The Transitional Care Manager identifies hospitalized high-risk, complex patients for program enrollment and communicates with all entities involved in the care of the patient to promote and maximize care coordination. Key aspects of the Transitional Care Program protocols are based upon inpatient and post-discharge workflows. Inpatient workflow includes participation in hospital multidisciplinary daily rounds, patient and family education regarding disease states and self-care, identification of patient-level concerns regarding discharge, social risk factor assessment, and anticipation of potential gaps in care. The inpatient encounters are designed to educate patients/caregivers surrounding their post discharge health care needs and to empower them to play an active and informed role in managing their care post-discharge. Upon patient hospital discharge, the post-discharge workflow is telephonic follow-up for 30 days, facilitating clinical care, patients access to appropriate services, and service referrals and appointments. This includes a focus on medication reconciliation and adherence, management of patient's quality of life and functionality, identification and rectifying gaps in care, assessment and support of patient's ability to perform self-cares, coordination of post-discharge appointments and services (durable medical equipment, home health), and coordination of care across the care continuum. The Transitional Care Manager utilizes research findings in practice and participates in MGB Post Acute Care Program design, implementation, and evaluation and participates in ongoing quality improvement activities. They collect clinical path variance data that indicates potential areas for system-wide improvement of cares and services and provides identifying errors and discrepancies in care that negatively impact the patient. Serves and protects the hospital community by adhering to professional standards, hospital care policies and procedures, federal, state, and local requirements, and Joint Commission on Accreditation of Healthcare Organizations (JCAHO) standards. Required for All Jobs Performs other duties as assigned Complies with all policies and standards Does this position require Patient Care (indirect/direct)? Yes Essential Functions A. Assessment 1. Navigates Epic reports and databases to identify patients for program enrollment 2. Identifies patient/family education needs and ensures that patient/family members have adequate information to participate in transition planning. 3. Critically evaluates and analyzes physical and psychosocial assessment data. 4. Interprets screening and selective laboratory/diagnostic tests. 5. Initiates and maintains communication and collaboration with physicians, social workers, care team leaders, staff nurses, other care giving disciplines, and patients/families to develop, implement, and evaluate a transition plan of care for each patient. 6. Conducts a comprehensive patient/family assessment and transition/home care planning evaluation upon program enrollment to initiate and maintain the patient's transitional plan of care. 7. Monitors the achievement of clinical outcomes and communicates with inpatient teams, primary and specialty physicians and staff, regional providers, and community resources (Home Health) regarding unanticipated variances. 8. Assesses complexity of care needs and potential/actual issues or gaps in care. 9. Arranges post-discharge medical and community referrals for patients with health problems requiring further evaluation and/or additional services. 10. Advocates for patients and families within the health care system with community providers and across the continuum of care. 11. Identifies, tracks, and conducts root cause analyses on readmissions to address programmatic and system-wide improvements. 12. Works with physicians, providers, researchers, and Post Acute Care leadership to identify broader system issues affecting patient care. B. Leadership 1. Coordinates and facilitates patient progression throughout the continuum. Collaborates with all members of the healthcare team and external customers. 2. Participates in clinical performance improvement activities to achieve set goals. 3. Applies advanced critical thinking and conflict resolution skills using creative approaches. 4. Supports Post Acute Care leadership with system-level quality improvement. Education
Can this role accept experience in lieu of a degree? No
Experience
Knowledge, Skills & Abilities
Mass General Brigham Medical Group Northern Massachusetts, Inc. is an Equal Opportunity 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. | |