DIRECTOR OF TRANSITIONAL CARE (HH)

Required Qualifications

1. Demonstrates an understanding of arithmetic and analytical principles necessary for evaluating outcomes and operational performance.
2. Must have a minimum of three (3) years of experience in transitional care post-acute case management or Home Health/ Hospice leadership; five (5) years preferred.
3. Bachelors degree in Nursing Healthcare Administration or related field required; Masters degree preferred.
4. In-depth knowledge of Medicare Medicaid insurance authorization processes and post-acute care transitions.
5. Demonstrated success leading teams to achieve measurable outcomes in readmission reduction length-of-stay optimization and quality metrics.
6. Strong communication leadership and relationship management skills with the ability to partner across multiple service lines and community providers to drive growth and clinical outcomes.
7. Proven ability to analyze data and trends to improve patient experience financial performance and transitional care outcomes.

Major Duties and Responsibilities

The Director of Transitional Care provides strategic and operational leadership to the Transitional Care Specialist team across home health and hospice locatioins ensuring excellence in outcomes patient satisfaction and seamless integration within the Rocky Mountain Care (RMC) continuum of services. The Director collaborates closely with the Administrator Regional Directors Clinical Operations and Business Development to support census growth regulatory compliance and the delivery of a consistent five-star patient experience.

Leadership & Oversight

1. Directs and supports Transitional Care Specialists in daily execution of referral management admission processes and care transition coordination.
2. Establishes outcome-driven goals related to hospital readmission rates referral conversion patient satisfaction and census growth.
3. Monitors and reports key performance indicators (KPIs) monthly to ensure consistent progress toward organizational objectives.
4. Partners with Business Development Central Intake Social Services and Nursing Leadership to create a culture focused on outcomes accountability and collaboration.
5. Oversees the onboarding education and performance management of Transitional

Care Specialists ensuring consistent application of RMCs standards and best practices.

Outcome Management & Quality Improvement

1. Leads initiatives to reduce hospital readmissions enhance length-of-stay efficiency and improve discharge outcomes.
2. Utilizes data analytics to evaluate referral patterns payer trends and care transitions for ongoing process improvement.
3. Collaborates with location and regional leadership to align outcome metrics with the

organizations Quality Assurance and Performance Improvement (QAPI) program.

1. Promotes evidence-based practices that enhance continuity patient satisfaction and overall clinical outcomes.
2. Implements corrective actions for locations not meeting outcome benchmarks providing targeted training and ongoing support.

Interdisciplinary Collaboration

1. Fosters open communication and coordinated care among the interdisciplinary team (IDG) hospital partners and post-acute service lines (SNF Home Health Hospice Assisted Living).
2. Ensures timely and accurate communication of referral status admission updates and discharge planning activities.
3. Serves as liaison to hospital case management provider groups and community agencies to strengthen referral relationships and streamline patient transitions.
4. Partners with the Business Office to maintain financial integrity through accurate payor verification and timely authorization management.

Patient Experience & Service Excellence

1. Champions RMCs Five-Star Service Model ensuring Transitional Care Specialists deliver a compassionate informed and proactive experience from admission through discharge.
2. Reviews patient and family feedback leading service recovery efforts when needed.
3. Conducts regular rounding with Transitional Care Specialists to ensure adherence to communication standards and timely follow-up on patient transitions.
4. Tracks and analyzes patient satisfaction scores and implements targeted improvement initiatives.

Continuum Growth & Business Development

1. Collaborates with marketing and external relations teams to increase facility census and strengthen RMC continuum utilization.
2. Develops relationships with hospitals provider networks and community partners to

promote RMCs integrated post-acute care services.

1. Ensures each facilitys Transitional Care team educates patients and families on

available RMC services (e.g. Home Health Hospice Assisted Living).

1. Participates in regional strategy meetings to align business development and care transition initiatives with enterprise goals.

Promotes teamwork mutual respect and effective communication.

Promotes safe work practices safety rules and accident prevention procedures to prevent employee injury and illness.

Additional Tasks

1. Treats all residents with dignity and respect. Promotes and protects all residents rights.
2. Establishes a culture of compliance by adhering to all facility policies and procedures. Complies with standards of business conduct and state/federal regulations and guidelines.
3. Follows appropriate safety and hygiene measures at all times to protect residents and themselves.
4. Maintains confidentiality of protected health information including verbal written and electronic communications.
5. Reports noncompliance with policies procedures regulations or breaches in confidentiality to appropriate personnel. Reports any retaliation or discrimination to HR or compliance officer.
6. Reports any allegations of abuse neglect misappropriation of property exploitation or mistreatment of residents to supervisor and/or administrator. Protects residents from abuse and cooperates with all investigations.
7. Reports any occupational exposures to blood body fluids infectious materials and/or hazardous chemicals in accordance with facility policy.
8. Participates in all life safety and emergency drills and trainings. Fulfills responsibilities as

assigned during implementation or activation of the facilitys emergency plan.

1. Reports work-related injuries and illnesses immediately to supervisor.
2. As a condition of employment completes all assigned training and skills competency.
3. Follows established infection control policies and procedures.

Personal Skills and Traits Desired/ Physical Requirements/Working Conditions

1. Ability to read write speak and understand the English language.
2. Must be a supportive team member contribute to and be an example of team work.
3. Ability to make independent decisions when circumstances warrant such action.
4. Ability to deal tactfully with personnel residents family members visitors government agencies/personnel and the general public.
5. Must have patience tact and willingness to deal with difficult residents family and staff.
6. Must be able to relay information concerning a residents condition.
7. Must not pose a threat to the health and safety of other individuals in the workplace.
8. Must be able to move intermittently throughout the workday.
9. Meets general health requirements according to facility policy including medical and physical exams and checking immunity status to various infectious diseases.
10. Ability to work beyond normal working hours and on weekends and holidays when necessary.

1. Ability to assist in evacuation of residents during emergency situations.
2. Ability to bend stoop kneel crouch perform overhead lifting and perform other common physical movements as needed for the position.
3. May be subject to falls burns from equipment and/or odors throughout the day; encounter reactions from dust tobacco smoke disinfectants and other air contaminants.
4. Subject to exposure to infectious waste diseases and/or conditions which include AIDS Coronavirus Hepatitis B and Tuberculosis.
5. May be subject to hostile or emotional residents family members visitors or personnel.
6. Works in office and throughout the facility.
7. Willing to work to task completion in spite of frequent interruptions.
8. Subject to hostile and emotionally upset residents family member personnel and visitors.
9. Works beyond normal working hours and on weekends holidays when necessary. On call 24 hours per day 7 days per week.

Compliance as a Condition of Employment and Performance Appraisal

Agreement to abide by all standards policies and procedures of the facility including the

facilitys compliance and ethics program is a condition of employment. Compliance will be a factor in evaluating job performance. Violations including failure to report violations will result in disciplinary action up to and including termination.

This job description is intended to convey the general scope of the major duties and responsibilities inherent in this position. Other tasks not listed here may be assigned by the Administrator. Periodic revision may be necessary to reflect changes in expectations placed on long term care by various governmental agencies. This job description will be reviewed and/or revised annually and as needed.

Individual performance will be evaluated using the following scale:

1. Unsatisfactory: Achieves results which are far less than the standards identified for the performance factors rated.
2. Needs Improvement: Achieves results which are less than the standards identified for the performance factors rated. Exhibits the potential to become a competent performer. May be new to job or need skill development.
3. Meets Standards: Achieves results which meet the standards identified for the performance factors rated. This rating is the expected level of performance.
4. Exceeds Standards: Achieves results which usually exceed the standards identified for the performance factors rated.

Reasonable Accommodation Statement

Consistent with the Americans with Disabilities Act (ADA) it is the policy of Rocky Mountain Care to provide reasonable accommodation when requested by a qualified applicant or employee with a disability unless such accommodation would cause an undue hardship. The policy regarding requests for reasonable accommodation applies to all aspects of employment including the application process. If reasonable accommodation is needed please contact Human Resources at or by email .