Remote Work Location Potential
The Post-Acute Care Liaison will work to improve post-acute provider performance metrics and transitions of care from hospital to post-acute care locations, specifically with partner skilled nursing facilities (SNF). This individual will be a liaison with SNFs and inpatient care coordination and will work as a care coordinator to follow Carle patients who are admitted at partner SNF locations. Job activities will include ensuring smooth transition from hospital to SNF, SNF to community, attending SNF weekly IDT/Medicare meetings, and working collaboratively with SNF to improve the quality of care of our mutual patients.
- Follow all Carle patients who discharge to a PACC SNF with SNFist providers including conducting chart reviews in preparation for weekly SNF IDT meetings.
- Attend weekly SNF IDT meetings to discuss and formalize plan of care and discharge planning.
- Conduct root cause analysis for post-acute patients for tracking and trending.
- Serve as the liaison between inpatient case managers and SNF to ensure smooth transition.
- Assist in the transition of patients back to community following SNF stay.
- Support development and dispersion of clinical education in partnership with SNFist team to share with SNFs.
- Assist SNF in implementation of industry best practices.
- Assist in ACO SNF 3-Day Waiver which includes, support in placement to SNF, weekly follow up with patient to update care management planand handoff to ACO RNs.
- Maintains relationships with skilled nursing facilities (SNF) that are characterized by patient-centeredness, collaboration and mutual respect.
- Serves as liaison between SNF and inpatient case management to ensure both parties are meeting set expectations.
- Identifies opportunities within SNF that will enable them to admit and successfully manage complex patients.