The Post-Acute Care Program assists with reducing hospital readmissions of clinically complex patients. The program couples patient education/coaching with Home Health interventions to assist a patient’s transition home after a hospital stay. Staff works directly with patients in transitioning from hospital to home with a focus on short term self-recovery in the home and long term ongoing care management of their healthcare. Assess patients care needs through assessments that are completed in home and/or telephonically, treatment plan creation to mitigate care gaps, facilitate in home health care services to accomplish the treatment plan patient goals, patient education/coaching along with adherence/compliance monitoring.
This position functions as the Supervisor of the Post-Acute Care team and primary point of contact for day to day clinical questions, concerns from internal and external clients and provides team leadership and guidance regarding patient centered interventions. Assists in development of Post-Acute Care training, job aids and tools and desk level procedures. Provides clinical oversight for clinical and non-clinical associates
• Supervises the Post-Acute Care team members (clinical/non-clinical), provides team leadership and guidance regarding patient centered interventions and oversees daily workload and makes assignments to ensure timely completion.
• Functions as lead clinical resource to all associates. Supports the management team with training, tools and clinical oversight for both clinical and non-clinical team members.
• Supervises all daily team activities, assigns tasks and responsibilities to appropriate team members. Monitors performance and productivity of team and individual members and takes appropriate action to ensure guidelines and goals of the department are met. Completes performance reviews and mentors the Post-Acute Care team members.
• Functions as the lead clinical resource to Post-Acute Care team. Audits Post-Acute Care cases and interventions to monitor outcomes, track/trend results and identify opportunities for process improvement.
• Works collaboratively with Provider Relations and provider network department to achieve desired goals.
• Works with the Clinical Management to implement best practices for care transitions, utilization and authorization management of selected home care services.
• Works with Clinical Management to support clinical and utilization management goals and objectives.
• Participates in special projects and performs other duties as assigned.
• Must perform other duties as required or assigned.
Associate's Degree or Diploma in Nursing/Practical Nursing or the equivalent and a clear and active Registered Nurse/LPN/LVN (based on allowable state practice act) license in any state(s) or jurisdiction in the United States is required.Licensed in the state where providing PAC services. Minimum of 4-6 years’ experience with thorough knowledge of healthcare, case management, re-engineering processes, managed care regulations, utilization management, contract terms/stipulations, capitation requirements and governmental home health agency regulations also required. Previous management / leadership experience strongly desired but not required. Licensed professionals are required to possess a current license to practice without restrictions. Knowledge of State and Federal regulations in regard to Utilization Management and accreditation standards i.e. URAC, NCQA preferred.
• Candidate will possess excellent writing, organization, communication, and interpersonal skills.
• Able to manage multiple tasks, be detail oriented, be responsive, and demonstrate independent thought and critical thinking.
• Candidate will possess excellent clinical knowledge and ability to lead and guide others to be successful.
CareCentrix maintains a drug-free workplace in accordance with Florida’s Drug Free Workplace Law.