Oversee the delivery of Post Acute Care (PAC) Program to ensure seamless patient transitions from inpatient facilities to SNFs and from SNFs to home, improving patient outcomes and quality of life
Design and deliver on the post-acute care delivery strategy for all attributed Evergreen patients, based on evidence-based practices and clinical guidelines to improve patient outcomes and ensure consistency in care management delivery
Establish and monitor Key Performance Indicators to measure the effectiveness of post-acute care initiatives
Accountable for achieving outcomes that reduce cost of care and improve clinical outcomes
Use data and analytics to identify trends, gaps, and opportunities for improvement
Create systems, structure and process to monitor appropriate level of care and care planning in SNF setting and intervene where necessary
Identify and allocate essential resources efficiently
Drive optimal performance of the PAC clinical team
Direct the PAC clinical team’s engagement with SNFs
Accountable for achieving outcomes that reduce cost of care and improve clinical outcomes
Proactive monitor and manage team performance, ensuring specific and real-time feedback, in alignment with Evergreen’s performance management philosophy
Coach up and support team member growth and development
Inspire and influence team to deliver the best-in-class care our patients deserve, close clinical gaps, and escalate barriers to you quickly
Drive patient engagement and involvement in their own care
Develop and implement strategies to engage patients in their care
Promote patient education and self-management to improve health outcomes and reduce utilization
Implement patient feedback mechanisms and a process to address feedback
Collaborate with key internal and external stakeholders to ensure aligned, high-quality PAC care delivery
Develop strong partnership strategy, systems and processes with SNF facilities to ensure optimal collaboration and to, gather feedback, and help to align clinical pathways to eliminate barriers to care and achieve optimal clinical quality
Partner with CMO, central clinical teams, learning and development, and operational leadership to roll out clinical education & training that supports the care management and quality program goals and standards
Collaborate with the technology and population health operations team to ensure clinical excellence as we operationalize clinical pathways, workflows, and processes; set goals for clinical excellence to drive high quality and reliability in care
Stay up-to-date on regulatory changes and industry trends, and incorporate into strategy and care delivery as needed
Ensure compliance with CMS and payer rules and regulations
Stay current with industry trends and best practices in post-acute care management and incorporate innovative approaches to enhance care delivery and achieve better health outcomes
Other duties consistent with this role, as assigned.
Requirements
You hold an unrestricted RN, NP, or PA state license
You have 10+ years of clinical leadership experience
You have a Master’s degree or higher related to education, quality, public health, business administration, health services research, or a related field is preferred
You have demonstrated experience in value-based care models and understanding their importance in improving patient outcomes and reducing healthcare expenditure
You are proficient in establishing and monitoring KPIs to measure the effectiveness of post-acute care care initiatives
You have proven experience leading significant improvements in clinical quality and outcomes for care delivery and/or managed care organizations
You have experience leading collaborative, consensus-generating committees or work groups with conviction and decisiveness
You’ve demonstrated a strong comprehension of clinical standards of care and a focus on quality of life for your patients
You have the tenacity required to drive initiatives forward, overcome obstacles, and achieve goals despite challenges
You understand that being dependable and reliable is critical to effective care delivery and you’re able to meet attendance and availability expectations
Skilled with MS Office Suite of products including Outlook and Teams
Able to work effectively in a primarily remote environment: Home internet must support a minimum download speed of 25 Mbps and upload speed of 10 Mbps. Cable, Fiber, or DSL connections hardwired to the internet device are recommended. Evergreen will provide remote employees with telephony applications and equipment to meet the business requirements for their role. Employees must work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information.
Benefits
Flexible time off policy
12 paid holidays per year
Medical, dental, vision and life insurance, including an HSA with employer match
Reimbursement for continuing medical education for eligible roles
A 401(k) program where Evergreen matches up to 4% of contributions
Paid parental leave
A robust training and development program that starts with onboarding and continues throughout your career with Evergreen Nephrology
Applicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard skills
clinical leadershipvalue-based care modelsKPI establishment and monitoringclinical quality improvementcare deliverypatient engagement strategiesdata analyticscare managementpatient educationregulatory compliance
Soft skills
team performance managementcoaching and developmentcollaborationinfluenceproblem-solvingdependabilitycommunicationdecisivenesstenacityorganizational skills
Certifications
RN licenseNP licensePA licenseMaster's degree or higher in related field