Post-Acute Facility Coordinator SNF, Full Time, RN or MSW required.

St. Lukes is proud of the skills experience and compassion of its employees. The employees of St. Lukes are our most valuable asset! Individually and together our employees are dedicated to satisfying the mission of our organization which is an unwavering commitment to excellence as we care for the sick and injured; educate physicians nurses and other health care providers; and improve access to care in the communities we serve regardless of a patients ability to pay for health care.

JOB DUTIES AND RESPONSIBILITIES:

• Coordinate activities related to ACO patients in post-acute facilities primarily SNFs and ARFs.

• Review clinical data and determine follow-up activities for specific patients using tools such as RealTime PointClickCare and EPIC

• Work with care management and other healthcare personnel to reduce post-acute utilization for patients in the ACO.

• Establish relationships with post-acute providers. This may necessitate either on-site or virtual meetings as deemed appropriate.

• Establish and coordinate quarterly post-acute collaborative meetings with post-acute providers and SLUHN key personnel.

• Maintain database related to key contacts at high volume and high performing post-acute facilities.

• Make recommendations for high-performing facilities based on objective data.

• Educate case managers and other healthcare personnel on post-acute activities related to the ACO.

• Working with St. Lukes ACO and Care Management leadership establish key metrics to monitor including but not limited to utilization LOS and readmissions.

• Identify trends and develop strategies to mitigate negative trends.

• Working with facility leadership promotes the use of Advance Care Planning (ACP).

• Participates in utilization management meetings at the SNF or acute rehab level as appropriate.

• Liaison between post-acute facilities and St. Lukes to convey information regarding SNF performance in relationship to ACO goals.

• Assists with clinical pathway development and adherence at the SNF level in conjunction with the administrative SNF or rehab teams and ACO leadership.

• Facilitate transitional care management meetings with post-acute providers.

• Develop working relationships with hospital interdisciplinary team members including but not limited to Case Managers Discharge planners Social Workers Coding Supervisors PT department etc.

• Have a working knowledge of the ACO goals and other risk-based contracts as it relates to post-acute utilization.

• Educate and help facilitate transition of patients to Preferred Provider Networks in the Post Acute Care setting (PAC)

PHYSICIAL AND SENSORY REQUIREMENTS:

Sitting for up to six hours per day for two hours at a time. Standing for up to four hours per day. Walking for up to three hours per day ten minutes at a time. Continually uses fingers and hands to manipulate objects. Occasionally lift carry or push objects up to 75 pounds. Very often stoops bends and reaches above shoulder level. Hearing as it relates to normal conversation. Seeing as it relates to general vision near vision peripheral vision and visual monotony. Ability to operate a vehicle independently.

EDUCATION:

Registered Nurse with current licensure or MSW required

TRAINING AND EXPERIENCE:

Minimum 1-2 years of discharge planning experience transitional care and/or post-acute services required; minimum 3 -5 years of healthcare experience required

Please complete your application using your full legal name andcurrent home address. Be sure toincludeemployment history forthe past seven (7) years including your present employer. Additionally you areencouraged to upload a current resume including all work history education and/or certifications andlicenses if applicable. It is highly recommended that you create a profile at the conclusion of submitting your first application. Thank you for your interest in St. Lukes!!

St. Lukes University Health Network is an Equal Opportunity Employer.