Care Transitions Program Manager / Per Diem / BWH Care Continuum

Wentworth-Douglass Hospital Boston , MA 02298

Posted 6 months ago


The Care Transitions Program Manager is responsible for overall management of the Brigham Health Care Transitions Program, including clinical and financial outcomes, along with Care Continuum Management (CCM) leadership. Working closely with Brigham Health Care Transitions patients, the Care Transitions Program Manager will follow ACO patients discharged to Brigham Health's (BH) skilled nursing facility network. Using established clinical decision support tools and LOS criteria, the Care Transitions Program Manager works with the collaborative SNF's to ensure the execution of efficient patient care plans within the approved LOS timeframe. Through onsite and telephonic rounding, the Care Transitions Program Manager develops relationships with SNF administrative and clinical staff in order to promote optimal and efficient patient care and connects patients back to BH providers upon discharge. This position requires a broad knowledge of academic medical centers, post-acute levels of care, health care re-imbursement, clinical systems / EMR's, case management expertise, prudent nursing judgment, critical thinking, sound problem solving skills, excellent organizational and interpersonal skills, creativity, flexibility, and the ability to multi-task.


  • Evaluates ACO patients referred for admission to skilled nursing facilities for level of care; utilizes and applies level of care and SNF length of stay decision support software at time of transition, during the SNF stay, and at time of SNF discharge.

  • In partnership with Care Transitions Project Manager, utilizes Epic, 4-Next, Patient Ping, and Care Transitions database to identify and track patients.

  • Hire and co-manage care transition specialist working with Medicare ACO patients

  • Facilitates coordination of care for ACO patients in skilled nursing facilities during the stay and at discharge; for iCMP patients, in collaboration with the iCMP RN Care Coordinators.

  • Establishes the anticipated length of stay for ACO patients at time of transition and monitors and provides length of stay guidance to the SNF facility.

  • Through onsite and / or telephonic rounding, ensures timely implementation of the plan of care at the SNF and appropriate patient progression to discharge, helping to navigate any barriers to care.

  • Visits Brigham Health Care Transitions patients and / or families to explain role, program, and ensure all elements critical to the plan and trajectory of care have been communicated, including the goal length of stay.

  • Participates in patient and family meetings, as needed, to support the plan of care and discharge plan. Advocates for patient and family as needed.

  • Communicates with PCP's, Specialists, iCMP RN Care Coordinators and / or other health care clinicians to provide routine warm hand offs or to alert providers about potential issues during or upon discharge from Care Transitions program.

  • Documents non-acute tracking notes in electronic medical record and routes messages to providers and clinicians as needed.

  • Performs Post Discharge Assessments (PDA's), including medication reconciliation, within established timeframes and documents in electronic medical record. Works to resolve any identified issues that could lead to an unnecessary re-admission.

  • Oversees and coordinates programs in collaboration with the management team

  • Determines resource requirements for designated programs. Make resource proposals as indicated

  • Contributes to the preparation and monitoring of the budget for Care Transition Program

  • Participates in Brigham Health Mini Collaborative and PHS SNF Collaborative Meetings, contributing to discussions, reviewing data, and focusing improvement efforts per established priorities.

  • Along with CCM leadership, reviews Care Transitions Program clinical and financial outcomes and recommends then executes program adjustments as indicated.


  • Demonstrates a positive attitude in dealing with problems or crisis situations.

  • Is aware of and follows BWH policies and procedures for general safety, fire safety, parking, proper body mechanics, infection control, attendance, punctuality, and appearance.

  • Works effectively with team members.

  • Demonstrates initiative and creativity to continuously improve services, processes, and other activities that affect quality and utilization.

  • Performs all duties in an independent, professional manner and requests assistance when necessary.

  • Work reflects excellent organizational skills.

  • Willingness to be flexible in situations. Performs duties of lesser, equal, or greater responsibility as requested.


  • Assumes accountability for professional growth and development.

  • Exemplifies program teachings and acts as a role model for patients by practicing behaviors consistent with goals of the program.

  • Assists in preparation for Joint Commission, CMS, and other surveys as applicable to role

  • Works within legal, regulatory, accreditation and ethical practice standards relevant to the position and as

  • established by BWH/Partners.

  • Follows safe practices required for the position.

  • Complies with appropriate BWH and Partners policies and procedures.

  • Fulfills any training required by BWH and/or Partners, as appropriate.

  • Brings potential matters of non-compliance to the attention of the supervisor or other appropriate

  • hospital staff.


  • RN, PT, or OT license required, BSN required. Master's Degree required.

  • Three to five years of acute care experience in an academic medical center, preferred.

  • Minimum of 3 years of case management, levels of care and discharge planning experience required.

  • Minimum of 2 years experience working in a post acute setting such as L-TAC, rehab, skilled nursing facility, or homecare preferred.

  • Previous management experience required

  • Ambulatory primary care experience preferred.

  • Managed care experience preferred.

  • Experience with health care finances preferred.

  • Experience using acute and post acute versions of utilization review criteria such as MCAP, Interqual, and/or Milliman preferred.


  • Excellent organizational and communication skills.

  • Excellent oral, written, and telephonic skills and abilities.

  • Superior interpersonal skills.

  • Knowledge and skills to differentiate levels of care and develop strategies to support patients and families.

  • Ability to work well with physicians and ambulatory staff in a practice or health center setting.

  • Strong competency working with hospital computer systems and case management systems.

  • Competent using Microsoft Word, PowerPoint, and Excel.

  • Ability to interpret clinical and financial data related to program performance.

  • Demonstrated ability to present and speak in front of groups.

  • Ability to handle routine work, unexpected priorities, and multi-task.

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Care Transitions Program Manager / Per Diem / BWH Care Continuum

Wentworth-Douglass Hospital