Post Acute Network Coordinator

at  RWJBarnabas Health

Req #: 0000173310
Category: Professional / Management
Status: Full-Time
Shift: Day
Facility: RWJBarnabas Health Corporate Services
Department: Accountable Care Organization

ESSENTIAL FUNCTIONS:

• Provides general oversight of the performance of 87 skilled nursing facilities, considered to be part of RWJBH s preferred network and representing over $60 million in Post-Acute spend, to ensure that quality, collaboration, and patient experience are maximized.
• Work as a Liaison between the post-acute care network facilities and RWJ Barnabas Health system for new and existing partnerships.
• Regularly review performance of RWJBH s high performing post-acute care network through quarterly scorecards, ACO Expenditure reports, and other reporting as available to understand each facility s performance in Value-Based payment models and other risk-based contracts.
• Meet with each SNF in the high performing post-acute care network intended to create regular channels of interaction, communicate changes, review performance, and understand opportunities for performance improvement.
• Identify performance gaps of the high performing post-acute care network overall, as well as for each individual facility, and develop strategies and corresponding action plans to improve performance.
• Collaborate with Post-Acute Care Coordinators, to ensure the continuity of care in discharge planning with patients families and other health care providers as appropriate, providing home instructions to patients and caregivers, recommending and or providing equipment/ home modifications, and recommending appropriate follow-up care if needed.
• Collaborate with Transition of Care Managers and any other care managers following patients in skilled nursing facilities to identify challenges, review specific care examples, and escalate concerns with facility performance as indicated.
• Meet regularly with RWJBH Leaders and Value Based Care stakeholders that intersect with high performing post-acute care network, such as Hospital leadership, case management, value-based care programs, health Plans, geriatric program, etc. to inform them of SNF performance, and ensure the network continues to serve the RWJBH system and optimize outcomes for our patients
• Annually, and as indicated, review overall network composition for performance and collaboration and provide recommendations for changes to be made to network membership
• Provide regular report outs to leadership boards and meetings to allow visibility into high performing post-acute care network

OTHER DUTIES:

Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities and activities may change at any time with or without notice.