Position Summary 

The Administrative Director of Transitions of Care is responsible for strategically developing, implementing, and evaluating safe, timely, high-quality patient care transitions across the continuum.  This leader is responsible for the overall daily operations of inpatient social work, care coordination, physical therapy, discharge planning, and utilization review and provides administrative oversight of Hunterdon Hospice and Home Health services. In this role, the Administrative Director of Transitions of Care collaborates with acute, subacute, and post-acute leaders within and outside Hunterdon Health to establish goals and ensure effective patient and organizational outcomes.  In addition to overseeing efficient operations, the Administrative Director is responsible for meeting/exceeding all financial metrics and maintaining necessary CMS, state, and specialty licenses, accreditations, and certifications for all services under their supervision.   

Primary Position Responsibilities 

1. Foster a comprehensive, cohesive, and coordinated approach to patient care, ensuring safe, cost-effective, and quality-driven outcomes across the healthcare system, including, but not limited to, Physician Specialists, Primary Care Physicians, PCMHs, Home Health Agencies, acute and Subacute Rehab, LTACH, Skilled Nursing Facilities, and Assisted Living. 

2. Provide leadership in planning, developing, organizing, implementing, and evaluating the continuum of care services in relation to the overall system goals of clinical quality, value, and patient satisfaction. 

3. Direct an interdisciplinary and cross-functional Care Coordination team to assist, facilitate, and coordinate discharge planning and utilize all potential resources. 

4. Ensure the discharge plan is specialized to the unique needs and risk scores of the patient/family/caregiver and that the patient's preference is always presented when choosing post-hospital care options. 

5. Collaborate closely with the Physician Advisor, Hospitalist Director, and Supervisor of Social Work to reduce LOS and increase opportunity days by ensuring that all inpatient clinical resources are utilized and effectively managed through frequent, timely team meetings and attendance at multi-disciplinary teams. 

6. Foster patient/family/caregiver engagement in all processes associated with transitions of care and patient experience with continuous improvement and development of programs based on both HCAHPS and Press Ganey data analysis and patient feedback. 

7. Ensure that Transitions of Care initiatives are implemented and executed via a daily strategic process involving a coordinated collaboration with MHCC and Practice Managers across the Integrated Delivery System, with efforts geared towards cost-effectiveness, reductions in readmissions, decreased use of the ER, and overall improvement in patient-centric care. 

 

Qualifications 

Minimum Education: 

Required: 

Bachelor’s Degree in Nursing and Master’s Prepared. If not Masters Prepared must be enrolled upon hire and completed within 5 years. 

Preferred: 

Certificate and/or Advanced Specialized Training in Care Coordination, Transitions of Care, Nurse Executive etc

 

Minimum Years of Experience (Amount, Type, and Variation): 

Required: 

Five years of clinical experience 

3-5 years of management experience in an acute care setting 

Preferred: 

One to two years of management experience, preferably in an acute care medical setting, to include direction of Care Coordination or Transitions of Care

 

License, Registry or Certification: 

Required: 

Current New Jersey RN 

Preferred: 

ANCC Certification

Knowledge, Skills, and/or Abilities: 

Required: 

Excellent verbal and written communication skills, excellent team building and team leadership skills, ability to facilitate strong interdisciplinary collaboration, a strong knowledge base of health care delivery systems, health care social work, discharge planning, and community resources. Strong internal and external relationship/networking skill set. 

Knowledge of current concepts in Care Coordination. Population Health, Social Work/Social Services, Case Management, and Discharge Planning with experience in patient care evaluation methodologies, criteria development, and data analysis techniques and applications.