Lead Care Transition Associate- PAH

Compassus•Santa Rosa, CA

About The Position

This position serves as the Supervisor/Lead Care Transition Associate to the Hub Team(s) and provides leadership and coordination for the home care services between Providence hospital facilities and the JV Agencies for home health and hospice, and other community providers when specifically requested by the patients. This position is responsible for identifying 'best practices' for care delivery and may network with community resources and consult with case management at the hospital. The Lead Care Transition Associate position is designed to support coordination efforts and may be assessed for success in achieving Value-Based Enterprise measures.

Requirements

Associate's Degree Or equivalent education/experience
High school diploma or equivalent plus three (3) years of work experience is equivalent to the Associate's degree.
(5) Five years of relevant professional work experience
Mathematical Skills: Ability to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals. Ability to compute rate, ratio, and percentage.
Language Skills: Ability to read, analyze, and interpret general business periodicals, professional journals, technical procedures, or governmental regulations. Ability to write reports, business correspondence, and procedure manuals. Ability to effectively present information and respond to questions from leaders, team members, investors, and external parties. Demonstrates history of successful presentation skills, sales and marketing results, preferably in healthcare related field. Communicates clearly, sensitively and in a supportive professional manner with patient/family/caregivers, co-workers and public. Strong written and verbal communications in English and excellent customer service communication skills by phone, email, and face-to-face.
Computer Skills: Proficient in using computers and knowledge of an Electronic Medical Record (as applicable) and Microsoft Office Suite programs. Knowledge of Electronic Medical Record (Epic) desired. Experience and knowledge of customer relational and territory management software.
Other Skills and Abilities: Ability to articulate and embrace integrated healthcare at home philosophy. Understands the purpose and function of Value-Based Enterprise agreement between Providence and JV for home health and hospice care coordination. Ability to develop positive working relationships with diverse and multicultural staff of ministry, community groups and individuals and applies and maintains strong team collaboration skills within and across ministries and builds strong relationships with operations and team members. Demonstrates strong leadership and supervisory skills; ability to inspire, motivate, and lead a team composed of a variety of disciplinary practices, and maintain positive professional development. Demonstrates competency by maintaining positive, collaborative, and constructive interpersonal relationships. Understands and practices the principles of effective teamwork. Demonstrates ability to work with minimum supervisory guidance and exercises independent judgment within the scope of practice; adapts easily to changes in work assignments and environment, can remain calm under pressure and is willing to assume additional responsibility and learn new procedures. Demonstrates ability to prioritize work assignments and meet productivity and quality standards through effective organizational skills and follow-through. Strong skills in facilitating complex problem solving and the ability to work with families/representatives in crisis. Ability to achieve annual referral and community educational requirements by prioritizing efforts and activities to support increased referral volume and achieve account penetration. Demonstrates flexibility and responsiveness working within a dynamic environment. Ability to follow appropriate communications channels and to travel throughout the service area from site to site and access multi-level buildings.
Driving may be necessary as part of this role. Caregivers are required to comply with all state laws and requirements for driving. Caregivers will be expected to provide proof of driver license and auto insurance upon request.

Nice To Haves

(3) Three years of staff supervision experience preferred.
(3) Three years home health, hospice and/or palliative care experience preferred.
Previous liaison, marketing, sales, or health care industry experience

Responsibilities

Provide administrative oversite to the care coordination liaison staff to include RN's and Care Transition Associates assigned to the hub.
Lead staff in problem-solving as needed.
Participates as a decision maker for escalated patients.
Coordinate adequate staffing schedule of liaisons and techs.
Ensure regulatory compliance for assigned staff; participate in development of polices and procedures to ensure compliance in accordance with standard home health & hospice procedures. Medicare Conditions of Participation and other regulatory agencies.
Maintain and build existing referral base relationships by serving as a resource for education and information.
Establish and maintain positive working relationships with facility customers and JV home health agency and hospice staff.
Evaluate referrals received on hospitalized patient from a variety of care settings for appropriateness for Home Health, Hospice, and/or other in-home services as appropriate.
Provide information to patients and their families interested in Hospice or Home Health.
Participates, when appropriate, in health care facility care conferences regarding specific patient consult requests.
Coordinate discharge planning for Hospice and Home Health patients who have been admitted to the hospital and act as a liaison to Ministry staff for smooth transition.
Accept referrals from hospital discharge planner after they have identified patient agency choice and type of home service needed.
Coordinate with the Inpatient Hospital Team and primary RN/MSW to ensure discharge planning is comprehensive and communicated efficiently.
Collaborate in Care Plan development, implementation and evaluation with discharge planners. Participates, when appropriate, in discharge planning rounds in health care facilities.
Appropriately document activities in the Providence at Home electronic medical system; tracks referrals received by nursing unit and accepted by each Providence at Home agency.
Maintains open positive communication with appropriate agency staff (Hospice, Home Health, and/or other in-home services) regarding referrals received.
Effectively manages customer resolution issues independently or seeks management/leadership involvement as needed.
Schedule, coordinate and present in-services and other information presentations at community events, health fairs, care-giver series, and other outreach activities.
In furtherance of the VBE care coordination goals, coordinate with Account Representative to support care coordination efforts; facilitate growth of Home Health andHospice services and promote Providence at Home according to growth strategies.
Actively participate in the development and execution of strategic initiatives that include increased Value Based Enterprise care coordination and discharge planning services for applicable post-acute care patients who will receive home health or hospice care following the hospital inpatient discharge.
Comply with all applicable Federal, State, and local laws, regulations, and requirements as well as facility specific policies and procedures. In addition, all employees who have contact with participants/residents/patients/clients are expected to promote the Patients' Bill of Rights and Responsibilities and understand the basic procedures for receiving and documenting grievances in order to initiate the appropriate process for participant concerns.
Maintain confidentiality of all patient demographics, medical and financial information at all times. Maintain confidentiality of all company and client information; ensure proper handling and disposal of confidential document and adheres to all HIPPA rules and regulations.
Additional duties may include the following: in collaboration with Care Liaison Manager and Regional Market Executive, lead local outreach team in execution of tactical plans to build business.
Lead team meetings to review and report weekly metrics and problem-solve customer service or account-related issues.
Provide support to local Team members for escalated customer service issues.
Respond to daily needs of local Team, including facilitation of excellent communication channels between Growth and Intake Department.
Serve as a local champion for service-line standardization and consistency efforts.
Performs other duties as assigned.
Acquire current knowledge of multiple managed care contracts and network provider subcontracts
Work cooperatively with Hospital discharge planning team to identify patients who would benefit from homebased care and to effectuate efficient and effective discharges in cooperation with patient's physician/mid-level provider.

Benefits

Meaningful Work: Make an impact every day by honoring the quality of life of our patients, supporting them and their families with compassion, and creating moments that truly matter.
Career Development: Access leadership pathways, mentorship, and personalized professional development.
Innovation Meets Compassion: Collaborate with a supportive team using the latest tools and technologies to deliver exceptional care.
Enhanced Benefits: Enjoy competitive pay, flexible time off, tuition reimbursement, and wellness programs designed for your well-being.
Recognition and Support: Be celebrated for your contributions through recognition programs that honor your dedication.
A Culture of Belonging: Thrive in a culture where you can be your authentic self, valued for your unique contributions and supported in a community that embraces diversity and inclusion.

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