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POSITION SUMMARY

This position is focused on coordinating and optimizing care transitions for ACO and select patients attributed to our value-based care arrangements who are transitioning from acute care to post-acute care and ultimately to home. This role ensures smooth transitions and effective communication among healthcare providers, patients, and various stakeholders to enhance patient outcomes and reduce healthcare costs.

ACCOUNTABILITIES

*All duties listed below are essential unless noted otherwise*

1. Identification of ACO patients in acute care and perform hand off to responsible individual coordinating patient’s discharge plan regarding eligibility for 3-day SNF waiver.

2. Effectively tracks patients who have transitioned into the post-acute facility setting.

3. Collaborates with post-acute facilities to enhance patient outcomes (i.e., expected length of stay, return to hospitals/readmissions, etc.).

4. Obtains weekly updates regarding discharge readiness and anticipated discharge dates for select patient.

5. Calls for and integrates discharge information for any patient discharged from a SNF into electronic medical record to fuel continuity of care post discharge.

6. Utilizes nursing clinical judgement to apply case management principles with patients to ensure optimal healthcare utilization, connectivity, and outcomes.

7. Contributes to special projects, as assigned.

8. Other duties as assigned.

Education: Associate or bachelor’s degree in nursing.

Years of Experience: At least 2 years of previous case management, care navigation, or post-acute care experience.

License: Must have active and unencumbered RN in Ohio and Michigan - or be willing to obtain upon hire.

PREFERRED QUALIFICATIONS

Education: Master’s degree in nursing or other relevant healthcare field.

Skills: Microsoft Office competency

Years of Experience: 2 years

ProMedica is a mission-based, not-for-profit integrated healthcare organization headquartered in Toledo, Ohio. For more information, please visit www.promedica.org/about-promedica

Qualified applicants will receive consideration for employment without regard to race, color, national origin, ancestry, religion, sex/gender (including pregnancy), sexual orientation, gender identity or gender expression, age, physical or mental disability, military or protected veteran status, citizenship, familial or marital status, genetics, or any other legally protected category. In compliance with the Americans with Disabilities Act Amendment Act (ADAAA), if you have a disability and would like to request an accommodation in order to apply for a job with ProMedica, please contact [email protected]

Equal Opportunity Employer/Drug-Free Workplace

**Requisition ID:** 96593