Major Responsibilities:Serves as the liaison between the hospital and the post acute network (PAN) skilled nursing facilities. Manage and facilitate communication between the inpatient care managers, external care providers and outpatient care managers for high risk patients transitioning in and out of the acute care setting and post acute programs. Assist the transition of high risk patients to post acute programs and eventually back to their primary care physician (PCP) and community.Monitors, collects and analyzes data to evaluate the effectiveness, safety and quality of patient care in the post acute care network programs.Addresses questions and concerns by providers, patients and families regarding post acute programs in coordination with other care teams. Acts as a conduit for problem solving, resolution and service recovery.Insures accurate placement of patients into the Post Acute Network program based on established criteria. Provides for Utilization Review for specific populations that need additional oversight.Interacts with hospital administrative teams and leaders., PHO Directors, Director of Case Management, Home Care Directors, Hospice Directors, Care Managers, Social Workers, Medical Directors, Physicians, APN's and Nurses. Facilitates communication with post acute providers at the skilled sites such as Nursing Home Administrators, Directors, Admissions staff, social services staff, nurses as well as Physicians SNFist and Advance Practice Nurses. Will have some contact with patients and families regarding post acute program and care options when service recovery and/or quality issues arise.Monitors which post acute program is appropriate for patients, problem solving for unique situations, best methods of data collection and transfer of information across sites. Finding effective ways to manage and "coach" our Sub-Acute Skilled Nursing Facility providers to shorten length of stay when appropriate, reduce re-admissions and increase utilization of Advocate Aurora providers. Evaluates utilization of resources, analysis of sentinel events and follow up on quality issues.Addresses issues of non-compliance with staff and MDs in regard to referring patients to appropriate programs. Serious quality issues or quality of care trends related to post acute providers. Recommendations for policies and procedures that can enhance the service delivery.Responsible for the relationships within their assigned territory and responsible for their assigned hospital, clinics and skilled nursing facilities within their territory. Other Post Acute providers such as physician offices, Home Health Providers and Assisted Living providers in the territory of the assigned hospital will be covered by the position. Coverage for other positions as needed on a short-term or permanent basis. Travels to meetings regularly with Skilled Nursing Facility Staff.Provides support to the clinical team assigned to the facility, removing operational barriers that will allow the clinical team to function at the top of their license and focus on the medical management of their panel.Responsible for understanding and adhering to the organization's Code of Ethical Conduct and for ensuring that personal actions, and the actions of employees supervised, comply with the policies, regulations and laws applicable to the organization's business.
Licensure, Registration, and/or Certification Required:Registered Nurse license issued by the state in which the team member practices, or
Education Required:Bachelor's Degree in Nursing.
Experience Required:Typically requires 5 years of experience in in healthcare industry, an acute setting, and 1 year of case management and quality improvement experience.
Knowledge, Skills & Abilities Required:Understanding of hospital and physician operations and post acute services impacted by managed care and health care reform. Thorough understanding of Medicare, Medicaid, Medicare Advantage and private insurance.Strong verbal and written communication skills.Excellent interpersonal skills necessary to interact with internal and external clientsDemonstrated ability to work well with physicians and other professionals.Must be detail-oriented and have excellent organizational skills.Must be proficient in Microsoft Office (Excel, Word, Power Point, Access) or similar products.Ability to work with data and think strategically and behave tactically for resultsAbility to handle difficult situations, conflict and maintain professionalism.Ability to work autonomously with minimal direction from supervisor.Excellent social skills and relationships. Strong creative problem solving and facilitation skills.Self-motivated.
Physical Requirements and Working Conditions:Must sit, stand, speak, read/write, and walk throughout the workday.This position requires travel so will be exposed to weather and road conditions.Local travel to area skilled nursing facilities and hospitals. May need to travel outside of assigned territory to assist another area. Travel in all weather conditions and neighborhoods with high crime rates. Early and late meetings as needed to establish contact with stakeholders, physicians and referral sources. Must be able to provide own vehicle to travel to post acute providers and meetings.Generally exposed to normal office environment.Operates all equipment necessary to perform the job.Occasionally lifts items weighing up to 20 lbs.
This job description indicates the general nature and level of work expected of the incumbent. It is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities required of the incumbent. Incumbent may be required to perform other related duties.