New 
Transitional Care Manager - Inpatient
 Mass General Brigham Community Physicians | |
 United States, Massachusetts, Newton | |
| 2014 Washington Street (Show on map) | |
 Nov 07, 2025 | |
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Primary Responsibilities:
- 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. 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. 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. What You'll Bring Requirements: - Bachelor's Degree or Master's Degree from an accredited program related to licensure. - Occupational Therapist Licensure, Physical Therapist Licensure or Physical Therapist Assistant Licensure. - 5+ years of experience, including 2+ years post-acute care coordination or case management experience. Preferences: - ACMA Certification as a Case Manager Additional Knowledge, Skills & Abilities:
Schedule and Work Model - Full-time (Monday through Friday, approximately 8:30am-5pm) - Hybrid: This role is on-site at Newton-Wellesley Hospital 75-80% of the timeand includes flexibility for either four days onsite and one remote, or five shorter on-site days (6-7 hours) with the remainder remote, based on hospital and patient needs. Mass General Brigham Community Physicians, 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. | |