Patient Transfer and Access Center Case Manager

About Us

The MGB Patient Transfer & Access Center (PTAC) Case Manager will have a unique opportunity to join a multidisciplinary, cross-institutional team of individuals who will play a central role in managing capacity on behalf of the eleven hospital MGB system. The PTAC's aim is to enable safe, efficient, and timely patient care by serving as the unified hub for system capacity management. The PTAC strives to help patients inside and outside of MGB gain access to high quality care within our system as efficiently as possible. To achieve this aim, the MGB PTAC Case Manager will work in close collaboration with teammates within the PTAC, colleagues at each member hospital, and other key stakeholders across the system.

A central pillar of the Patient Transfer & Access Center (PTAC) is to strengthen system-wide capabilities that optimize patient inflow and outflow at MGB hospitals and other MGB assets. The PTAC Case Manager will play a lead role in these critical activities, including serving as the chief manager for the Repatriation program (i.e. transfer-back of patients from higher level of care hospitals to their originating community hospitals once clinically appropriate). The Repatriation Program has been demonstrated to save more than two thousand bed-days annually at MGB academic medical centers, with a multimillion-dollar revenue impact associated with backfilling capacity with patients in need of access to tertiary care.

The Patient Transfer & Access Center (PTAC) Case Manager will achieve the aims of the role by adopting a 'system Enterprise mindset' with strong situational awareness of capacity throughout MGB and striving to leverage appropriate pathways and processes that optimize capacity and ensure timely access to care for patients throughout the system. The Case Manager will coordinate closely and collaborate openly with colleagues within the MGB PTAC, including Access Nurses, Specialty Desk representatives, and leadership, as well as with staff based at MGB and non-MGB hospitals and facilities. The Case Manager will closely partner with MGB Continuing Care Management (CCM) and hospital-based case management leadership, serving as an expert representative of Case Management from the MGB PTAC. The Case Manager will be a valued member of the PTAC team and their input, feedback, and recommendations will be regularly sought by leadership to further strengthen our system-based capacity management and achieve our collective goals to improve patient care.

Principal Duties and Responsibilities:

• Organizational Relationships:
  • Reports to the MGB Patient Transfer & Access Center (PTAC) CM Manager/Repatriation Program Director.
  • Coordinates closely with Access Nurses, Specialty Desk colleagues, and others that are co-located in the MGB PTAC.
  • Collaborates openly with MGB hospital-based Case Managers, capacity leaders and staff, including physicians and nurses.
• Scope and Responsibilities:
  • Serves as a representative and liaison for Case Management within the MGB Patient Transfer & Access Center (PTAC) to MGB CCM and hospital-based Case Management leadership.
  • Monitors system-wide capacity and develops strong knowledge of hospital and non-hospital assets (e.g., Home Hospital, etc.) throughout MGB as well as capabilities at non-MGB facilities. Strives to always match patient need with site of care to optimize capacity and access across the MGB system.
  • Inflow
    • Repatriation Program:
      • Manages and coordinates Repatriations across MGB. This includes:
        • proactively identifying candidates among patients transferred to or within MGB
        • preparing, sending and receiving hospital teams for Repatriation (including education and answering program-related questions)
        • tracking the patient during their hospital stay
        • coordinating with the unit-based Case Manager to initiate Repatriation
        • arranging transportation and working with the originating hospital to receive the patient back.
      • Escalates barriers encountered during Repatriation and receives support from MGB Patient Transfer & Access Center (PTAC) teammates and leadership.
      • Documents Repatriation activity in the appropriate databases.
      • Maintains data and creates reports summarizing Repatriation volume, barriers, and impact. Documents and maintains data regarding any quality and safety issues that are brought to their attention with Repatriation.
      • Provides guiding recommendations to MGB PTAC leadership regarding how to improve Repatriation.
      • Participates in quarterly meetings with stakeholders at hospitals and hospital systems that are key partners for Repatriation. This includes summarizing data, identifying barriers, and sharing ideas regarding opportunities to improve Repatriations with these partners.
      • Builds and maintains strong relationships with colleagues at hospitals that are partner destinations for Repatriation.
      • Helps the MGB PTAC develop new relationships with hospitals and systems that have historically not participated in Repatriation with MGB.
      • Teaches and guides hospital-based Case Managers on Repatriation.
      • For patients transferring from hospitals and those being referred into MGB EDs and inpatient spaces, works to identify and manage scenarios in which a patient may benefit from alternative levels of care or alternate placement:
    • Out of Network Transfer Requests - identifies non-emergent patients who are transferring to an MGB hospital that is out-of-network for their insurance, informs the referring hospital, the accepting MGB attending, and other Patient Transfer & Access Center (PTAC) staff. Determines in collaboration with colleagues whether to redirect the referring hospital to another in-network hospital and/or initiates work to obtain prior authorization for transfer to MGB.
    • Out-of-State and Transfer Requests with Anticipated Difficult Disposition - reviews transfer requests from out-of-state to identify patients who are expected to face substantial barriers to disposition out of the hospital. Alerts PTAC teammates and educates them on these barriers. Works collaboratively with colleagues to identify options for these patients and/or with hospital-based Case Management to initiate efforts to address these issues early in their hospitalization.
    • Home-based Services - well-versed on home-based options available within MGB. Helps guide and support MGB PTAC colleagues seeking to route patients to non-inpatient, non-ED services that are safe and appropriate.
  • Outflow
    • Works closely with colleagues in the Specialty Desks within the MGB Patient Transfer & Access Center (e.g., CCM, Transportation, and DME Specialty Desks) to help address barriers to discharge that are escalated from the MGB hospitals or other assets.
    • Provides hospital-based Case Management leaders with summary situational awareness about system-wide hospital capacity, post-acute availability, transportation, and other domains critical to outflow within the scope of Case Management.
• Participates in MGB huddles representing Case Management.
• Completes other duties as assigned
• Uses the Mass General Brigham values to govern decisions, actions, and behaviors. These values guide how we get our work done: Patients, Affordability, Accountability & Service Commitment, Decisiveness, Innovation & Thoughtful Risk; and how we treat each other: Diversity & Inclusion, Integrity & Respect, Learning, Continuous Improvement & Personal Growth, Teamwork & Collaboration

Qualifications

Qualifications:

• Graduate of an approved school of nursing, BSN required. MSN preferred. Current license to practice as a registered nurse in the State of Massachusetts. Case Manager Certification preferred.
• 5+ years of Case Management experience at an acute care hospital.
• Must have extensive knowledge of case management.
• Experience designing and/or utilizing innovative approaches to optimizing capacity, inflow/outflow, and saving bed-days preferred.
• Experience with Repatriation preferred.
• Continually updates clinical knowledge and skills through formal and informal education and review of the current literature
• Must work well independently, and have sound decision making skills

Skills/Abilities/Competencies:

• Leadership qualities to include:
  • Adopts a 'system mindset' - utilizes hospital-based experience to help build new system-level processes while being open and eager to learn other approaches from across MGB. Continually seeks to identify ways in which MGB can help support its patients and hospitals regardless of location. Values and seeks the input of colleagues based at MGB hospitals.
  • Willingness to work with MGB PTAC leadership and other Case Management and CCM leaders to design, build, and implement new processes in an environment that requires innovation and iterative improvement of new processes.
  • Strong interpersonal and customer service skills.
  • Problem solving, sound judgment.
  • Ability to prioritize and manage multiple responsibilities.
• Acute hospital experience preferred
• Case Management experience in an acute hospital setting and Utilization Management experience/knowledge preferred
• Strong assessment and problem-solving skills
• Strong interpersonal skills
• Ability to work independently with minimal supervision
• Goal oriented and accountable
• Demonstrated organizational skills
• Demonstrated ability to work in a complex setting
• Ability to work in an interdisciplinary team-based environment
• Strong oral and written communication skills
• Excellent communication skills.
• Attention to detail.
• Willingness to suggest and assist with improvements to policies, procedures, and process for referrals.
• Interest in hospital-wide and other asset-based capacity challenges and understanding of downstream effects of patient inflow on the whole system.

Supervisory Responsibilities:

No direct reports; may indirectly provide leadership and guidance to less seasoned and new staff

Working Conditions:

• General Business/Healthcare Office and clinical treatment areas.
• The MGB PTAC Case Manager Nurse will work in the MGB PTAC in the Assembly Row Building. This role is on-site initially with hybrid work options available after completing orientation and will be at the discretion of the PTAC CM Manager.
• This role is office-based; nurses will not provide clinical care to patients.
• The MGB Capacity Case Manager (as an entity) is a M-F per week role. There may be opportunity for weekend hours/coverage in the future based off program and organizational needs.
• While performing the duties of this job, the employee is frequently required to sit; talk; or hear; use hands to finger; handle; or feel; reach with hands and arms. The employee is occasionally required to stand; walk; and stoop; kneel; or crouch. The employee must frequently lift and/or move up to 5 pounds and occasionally lift and/or move up to 20 pounds. Specific vision abilities required by this job include close vision, distance vision and depth perception.
• The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Normal office working conditions. The noise level in the work environment is quiet to moderate.

EEO Statement

As a not-for-profit organization, Mass General Brigham is committed to supporting patient care, research, teaching, and service to the community. We place great value on being a diverse, equitable and inclusive organization as we aim to reflect the diversity of the patients we serve. At Mass General Brigham, we believe in equal access to quality care, employment and advancement opportunities encompassing the full spectrum of human diversity: race, gender, sexual orientation, ability, religion, ethnicity, national origin and all the other forms of human presence and expression that make us better able to provide innovative and cutting-edge healthcare and research.