Location: Dover,NH, USA
About UsWentworth Health Partners (WHP), an affiliate of Wentworth-Douglass Hospital and member of Mass General Brigham Medical Group, is a multi-specialty group practice providing the highest quality patient care and services that range from wellness and illness prevention to testing, treatment and care of complex medical conditions. Our network offers primary care, specialty care, and other services at locations throughout the New Hampshire and Southern Maine Seacoast Region.At WHP, we value people who contribute to patient-centered care that enhances community health; we recognize and reward those who share our values and transform our patients' lives. We invite you to explore opportunities, cultivate community wellness, and experience professional growth - join our team today!The OpportunityWe are seeking a part-time Transitional Care Manager to join our team! The part-time schedule will be 20-hours per week, ideally Monday-Thursday 9am-2:30pm, with some flexibility.The Transitional Care Manager (TCM) coordinates care for risk contract patients and helps guide them through the transition from one level of care to another. The coordination of care is accomplished through collaboration with the patient, family members, acute and post-acute interdisciplinary teams, and home care. The goal is to optimize patient care transitions thereby reducing unnecessary utilization of services and decreasing the risk of readmissions.Through these coordination efforts the TCM works to improve patient care transitions by:1) assisting in setting appropriate patient and family expectation2) assuring appropriate utilization of service3) assisting interdisciplinary teams in developing an appropriate discharge plan4) communicating care needs with both primary care and community supports to decrease the likelihood of readmission.The TCM will:Work with the acute interdisciplinary team to determine the appropriate level of post-acute care for risk-contact patients.Coordinate care for patients discharged to an associated skilled nursing facility (SNF) networkAt the associated SNF, the TCM develops a relationship with SNF administrative and clinical staff to promote optimal and efficient patient care; TCM efforts will be coordinated through both onsite and telephonic rounding.By using established standard operating procedures, clinical decision support tools, and length-of-stay (LOS) criteria, the TCM will work with the SNF to ensure the execution of efficient patient care plans within the approved LOS timeframe and connect patients back to Wentworth Douglass/Mass General Brigham providers upon discharge.The TCM will demonstrate careful professional and clinical judgment, effective problem-solving skills, critical thinking, excellent organizational and interpersonal skills, flexibility, and the ability to multi-task. In addition to the above, the TCM will stay up to date in matters relating to care coordination, applicable Federal and State regulations, risk management, community resources, and other pertinent continuum of care topics.Are you ready to bring your talent to this team and join us in moving health care forward?QualificationsQualificationsRequired:Physical Therapist (PT) or Physical Therapist Assistant (PTA) or Occupational Therapist (OT).Graduate of an accredited program related to licensure.Bachelor's degreeMinimum 2+ years of experience of acute hospital or post-acute care setting required.Evidence of continued education and professional development.Flexibility with tasks and assignments as program needs dictate. Examples include assisting colleagues and providing coverage during vacations/unexpected illness/holiday time.This position requires a broad knowledge of community hospitals, post-acute services, clinical systems, electronic medical records(EMRs), and rehabilitative expertise. Additionally, a broad knowledge of clinical care, payer rules including but not limited to Medicare, and health services across the continuum of care are required.Strongly Preferred:Minimum of 2+ years of case management, utilization review and discharge planning experience preferred.Knowledge of Medicare regulations and guidelines at SNF preferred.Experience with basic Microsoft Excel, PowerPoint, and Word preferred.EEO StatementMass General Brigham 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.