BFT Aspire Camp Staff - Transition Specialist
 Massachusetts General Hospital | |
 United States, Massachusetts, Somerville | |
| 399 Revolution Drive (Show on map) | |
 Jul 25, 2025 | |
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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.
Responsible for coordinating the transfer of patients between different levels of care, such as from the hospital to a skilled 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 Work closely with healthcare providers to plan and coordinate the timely and safe discharge of patients, ensuring that necessary services Identify and connect patients with appropriate community resources, home health services, durable medical equipment, and other support Provide patients and their families with education about their medical conditions, medications, self-care techniques, and follow-up care Document all care coordination activities, assessments, and interventions accurately in the patient's electronic health record (EHR) to Advocate for patients' needs during the discharge process, ensuring that they have access to appropriate care and support services upon 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. 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. Physical Requirements
The General Hospital Corporation 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. | |