Post-Acute Care Associate

Navvis & Company LLC • Boston, MA

134d

About The Position

As part of our In-Market team you will play an instrumental role in a department that is providing fully coordinated patient care from a holistic approach to improve the overall performance of the value-based population across the healthcare continuum by ensuring the population receives the right care, at the right time, by the right people. The RN/PT/SW Post-Acute Care Associate evaluates patient status at their current level of care and collaborates with the facility/agency care team to ensure the patient is advanced to the next level of care when appropriate.

Requirements

• Education: LPN, RN, PT, SW, OT, OTA, PTA.
• 3-5 years experience in Nursing, Physical Therapy, or Social Worker with following complex cases, discharge planning, and managing relationships with acute and post-acute facilities.
• A personal commitment to a person-centered approach, along with strong relationship building, communication, and active listening skills.
• Unrestricted Nursing, Therapy, or Social Work license in Massachusetts with the ability to be licensed in other states as needed.
• Previous proven experience as an accountable, high-functioning, high-performer.
• Willingness to perform duties of going into the post-acute facilities and work independently.

Responsibilities

• Manage the transition of care for patients being discharged from the hospital into post-acute care settings.
• Perform initial and on-going assessments of patient's condition.
• Establish, revise and evaluate a plan of care which is appropriate to problems identified and involves the patient/family.
• Provide education to patient/family/staff by assessing patient/family educational needs.
• Provide for continuity of care by participating 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, recommending appropriate follow-up care if needed and support hand-off to care management program when appropriate.
• Attend care planning conferences in the post-acute settings as indicated.
• Coordinate care of the patient between multiple stakeholders including the patient, the post-acute facility staff, the primary care team and the lead care manager.
• Understand the expected length of stay for the patient’s condition, review and discuss progress of the patient during the stay and influence discharge planning activities based on the patient's response to therapy and the need for skilled intervention.
• Complete Transition of Care notes for PCP: Follow patients 30 days post discharge.
• Review assigned facility data to identify opportunities to improve performance on KPIs.
• Manage relationships with current facilities ensuring appropriate engagement with Tufts Medicine.
• Support resolving patient placement escalations through creative problem solving, facility collaboration, and patient advocacy.
• Work collaboratively with facilities and system stakeholders to build action to address gaps in performance.
• Identify opportunities for education and support development and follow-up with facilities for additional questions.
• Ensure/provide appropriate education and coaching on utilizing Best Practice Tools in huddles for all facilities.
• Perform other duties as assigned.

Benefits

• Competitive total rewards strategy.
• Volunteering and social engagement activities.
• Paid Time Off plan starting at 2+ weeks.
• Medical, dental, vision insurance.
• 401K with a safe harbor contribution.

What This Job Offers

• Career Level: Entry Level
• Education Level: No Education Listed