Essential Functions

Serves as the liaison between the hospital and the post-acute network (PAN) skilled nursing facilities. Manages and facilitate communication between the inpatient care managers, external care providers and outpatient care managers for patients transitioning in and out of the acute care setting and post-acute programs. Assist the transition of 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. Reviews readmissions, analyzes root causes, develops and implements action plans.  May participates in quality, readmission and other committees as needed.   

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.

Ensures 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., 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 SNF 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. Finds 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 regarding 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.

Physical Requirements
Work requires walking, standing, sitting, lifting, reaching, stopping, bending, pushing and pulling. Working in fast-paced clinical setting. Must be able to lift and support the weight of 35 pounds in handling patients, medical equipment and supplies. Must speak and understand English fluently and have an intact sense of sight, hearing, smells, and finger dexterity. Critical thinking and ability to concentrate. Must be able to be mobile with the entire healthcare system and other facilities. Must be able to respond quickly to changes in patients and/or program conditions.

Education, Experience and Certifications

Bachelor’s degree or equivalent in Nursing or related field and/or Masters in Social Work

Registered Nurse license issued by the state in which the team member practices, Or Licensed Clinical Social Worker (LCSW) or LCSW-A working towards full licensure with certification in Certified Case Management (CCM)

Typically requires 5 years of experience in in healthcare industry and 1 year of case management and quality improvement experience.

Preferred

Experience in post-acute setting, care management and utilization management.