National Director of Transitional Care and High-Risk Patient Management
The Director of Transitional Care and High-Risk Patient Management (TCM & HRPM) will be responsible for the end-to-end program effectiveness to build and establish operational and strategic goals and objectives consistent with PCO Strategic Initiatives. Will lead and oversee the strategic planning, development, and execution of initiatives aimed at optimizing patient care transitions across the primary care continuum. The incumbent will play a pivotal role in reducing acute care utilization for top 5% of complex patients and ensuring seamless transitions of care for patients within the Primary Care Organization (PCO), hospital systems, and other patient care facilities that ultimately improve care standardization and resource utilization, reduce readmissions and enhance/optimize patient outcomes, satisfaction, and operational efficiency.
Coordinate quality improvement activities to address high risk, high-utilizers/high-cost patient management through the utilization of the 5M’s framework as well as transitions of care, best practices to guide policy and procedure development derived from the best evidence practices.
Provide ongoing program support through active communication, education, and consultation with clinical staff and leaders. Responsible for communicating with key stakeholders across the organization while creating communications and coordinating statistics and analysis of data to track and trend for the purpose of improving programmatic and performance on issues related to reducing acute care utilization, safe transitions, readmission reduction, and other clinical programs as determined.
Major Duties and Responsibilities
· Build and establish end to end operational and strategic goals and objectives consistent with PCO Strategic Initiatives.
· Formulate and achieve national objectives, goals, and strategies (clinical, economic), integrate practice standards, and collaboratively assess the effectiveness of each program, new opportunities, and develop actionable plans to meet growth and programmatic objectives.
· Evaluate the progress of programs or services by benchmarking best practices and identifying measurable outcomes, including the effective transitions of care activities and the implementation of the 5Ms framework (Mobility, Mind, Medications, Multi-complexity, and What Matters Most) to address and focus on the whole person, their quality of life.
· Establish collaborative relationships and work with operational and strategic key stakeholders, including clinical teams and care integration team (CIT) leadership to align on program goals, process/system improvements, and needs. May facilitate cross- functional performance improvement teams.
· Assist in developing written policies and procedures and practice protocols pertinent to the transitional care program and high-risk patient management.
· Build and implement feedback loops and monitoring mechanisms with CIT and market primary care teams, to identify needs and opportunities for program improvement.
· Create, collect, and coordinate metrics and analysis of data to track and identify any trends or anomalies for the purpose of improving programmatic and performance on issues.
· Demonstrate a thorough understanding and use of data systems to drive decisions and plan/implement performance improvement strategies.
· In certain cases, will oversee and direct sub teams/functions or dotted line sub teams/functions (e.g., outreach function in call center or directly and other related integrated care teams).
· Produce project work plans, timelines, and reports identifying and communicating key benchmarks for use in evaluation.
· Devise communication strategies to keep internal and external stakeholders informed of TCM initiatives and programs.
· Encourage and support innovative approaches to TCM practices in relation to expected standards across the continuum of care and provide ongoing avenues for orientation and continuing education for staff.
· Collaborate and partner in the execution of TCM workflows and processes to ensure comprehensive patient education programs that assure quality and appropriateness of care across settings (i.e., inpatient, ambulatory, and home).
Required Qualifications
· Bachelor or Master’s Degree in Nursing, Social Work, or a related Healthcare professional degree
· Minimum of 5-7 years of successful leadership experience overseeing a multi-region scale health care management program development and implementation with a focus on care transitions, post-acute care and high-risk management and care coordination.
· Experience with case management, social work, skilled nursing facilities, rehab programs, etc.
· Proven ability to move the needle on clinical quality outcomes (e.g., avoidable hospitalizations, ER visits, readmissions, total cost of care, and reducing acute care utilization).
· Familiarity in integrated care management programs with primary care.
Preferred Qualifications
· Master's degree in health care administration, business administration or related field.
· Experience working in a complex value-based health care organization.
Knowledge/Skills/Abilities/Competencies Required
· Strong leadership skills with the ability to build and lead high-performing teams.
· Excellent communication and interpersonal skills with the ability to communicate effectively with stakeholders at all levels.
· Strong analytical and problem-solving skills with the ability to develop and implement metrics to measure the effectiveness of care transitions.
· Understanding of clinical operations and ability to guide priorities, process development and implementation.
· Understanding of quality and value drivers in full risk care delivery, ideally in Medicare/seniors
· Demonstrated ability to work collaboratively with clinical and operational leaders across a complex health care organization.
· Knowledge of health care regulations and policies related to care transitions and post-acute care management.
· Computer skills in word processing, database management, spreadsheets, and report writing.
· Proficiency in tracking and evaluating process/system outcomes and performing and monitoring rapid cycle process improvement.
· Excellent project and program management skills
· Demonstrated ability for complex clinical decision making
