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Job Summary
Aspire is a program of Mass General Brigham that serves teens and young adults with social cognition challenges, including Asperger’s Syndrome, High-Cognitive Autism, Nonverbal Learning Disorder, and autism spectrum disorder that focuses on helping teens develop increased self-awareness, social competency, and stress management skills.
Qualifications
Responsible for coordinating the transfer of patients between different levels of care, such as from the hospital to a skilled
nursing facility, home health agency, or outpatient care by working collaboratively with healthcare teams, patients, families, and external
providers to ensure the continuity of care and facilitate successful transitions.
Collaborate with the healthcare team to develop comprehensive care transition plans for patients, taking into account their medical, social, and emotional needs.
Conduct thorough assessments of patients' physical, psychological, and social conditions to determine the most appropriate post-discharge
care setting.
Work closely with healthcare providers to plan and coordinate the timely and safe discharge of patients, ensuring that necessary services
and resources are in place.
Identify and connect patients with appropriate community resources, home health services, durable medical equipment, and other support
services to facilitate a smooth transition from hospital to post-acute care.
Provide patients and their families with education about their medical conditions, medications, self-care techniques, and follow-up care
instructions to promote better health outcomes after discharge.
Document all care coordination activities, assessments, and interventions accurately in the patient's electronic health record (EHR) to
ensure continuity of care and compliance with regulatory requirements.
Advocate for patients' needs during the discharge process, ensuring that they have access to appropriate care and support services upon
leaving the hospital.
Education: bachelor's degree Nursing required
Nursing Experience: 2-3 years required, and Care Coordination/Case Management Experience 1-2 years preferred
Knowledge, Skills and Abilities:
Familiarity with healthcare systems, post-acute care services, and community resources that support care transitions.
Understanding of healthcare regulations and guidelines related to care coordination.
Excellent communication and interpersonal skills to effectively interact with patients, families, healthcare teams, and external providers.
Strong critical thinking and problem-solving abilities to assess complex patient situations and develop appropriate care plans.
Ability to prioritize tasks and manage time effectively in a fast-paced hospital environment.
Additional Job Details (if applicable)
Physical Requirements
Standing (67-100%)Walking (67-100%)Sitting Constantly (67-100%)Lifting Occasionally (3-33%) 20lbs - 35lbsCarrying Occasionally (3-33%) 20lbs - 35lbsGross Manipulation (Handling) Constantly (67-100%)Fine Manipulation (Fingering) Frequently (34-66%)Feeling Constantly (67-100%)Vision - Far Constantly (67-100%)Vision - Near Constantly (67-100%)Talking Constantly (67-100%)Hearing Constantly (67-100%)
Remote Type
Onsite
Work Location
399 Revolution Drive
Scheduled Weekly Hours
0
Employee Type
Temporary
Work Shift
Day (United States of America)
Pay Range
$17.36 - $23.80/Hourly
Grade
2
EEO Statement:
The General Hospital Corporation is an Equal Opportunity Employer. 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. To ensure reasonable accommodation for individuals protected by Section 503 of the Rehabilitation Act of 1973, the Vietnam Veteran’s Readjustment Act of 1974, and Title I of the Americans with Disabilities Act of 1990, applicants who require accommodation in the job application process may contact Human Resources at (857)-282-7642.
At Mass General Brigham, our competency framework defines what effective leadership “looks like” by specifying which behaviors are most critical for successful performance at each job level. The framework is comprised of ten competencies (half People-Focused, half Performance-Focused) and are defined by observable and measurable skills and behaviors that contribute to workplace effectiveness and career success. These competencies are used to evaluate performance, make hiring decisions, identify development needs, mobilize employees across our system, and establish a strong talent pipeline.