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Organization:

SHSO-Sutter Health System Office-Bay

Position Overview:

Responsible for overseeing the coordination and management of patient care as they transition from the acute hospital setting to post-acute care services. This includes skilled nursing, home health, hospice, rehabilitation, and long-term care facilities. Works closely with the hospital's case management team, physicians, and post-acute care providers to ensure a seamless continuum of care. Using strong clinical expertise, knowledge of post-acute care services, and leadership in driving performance and ensuring quality outcomes for discharged patients. Successfully manage operations across multiple facilities, ensuring a smooth continuum of care and alignment with system-wide goals.

Job Description :

These Principal Accountabilities, Requirements and Qualifications are not exhaustive, but are merely the most descriptive of the current job. Management reserves the right to revise the job description or require that other tasks be performed when the circumstances of the job change (for example, emergencies, staff changes, workload, or technical development).

JOB ACCOUNTABILITIES:

• Oversee the planning, coordination, and implementation of post-acute care services for patients transitioning from the acute hospital setting.

• Develop and maintain relationships with post-acute care providers, including skilled nursing facilities (SNF), home health agencies, hospice, rehabilitation centers, and long-term care facilities.

• Ensure that patients receive high-quality, timely, and appropriate post-acute services that align with their clinical needs and discharge plans.

• Collaborate with case management teams, discharge planners, physicians, and nursing staff to facilitate smooth transitions of care and reduce hospital readmissions.

• Lead efforts to optimize post-acute care partnerships, ensuring contractual agreements and performance metrics meet hospital goals.

• Track and report on key performance indicators (KPIs) such as hospital readmissions, patient outcomes, and post-acute care utilization.

• Ensure compliance with federal, state, and local regulations related to post-acute care services.

• Identify opportunities for process improvement and implement strategies to enhance post-acute care coordination, patient satisfaction, and outcomes.

• Provide leadership, mentoring, and development opportunities for post-acute care staff, ensuring they have the skills and resources needed to succeed.

• Collaborate with finance teams to manage budgets and optimize the financial performance of post-acute services.

Development and Maintenance of Preferred Provider Network:

• Establish and maintain a network of preferred post-acute care providers, including SNFs, home health agencies, rehabilitation centers, and hospice care providers, ensuring high-quality and efficient patient care transitions.

• Conduct ongoing evaluations of preferred providers to ensure they meet the system’s standards for care quality, patient outcomes, and regulatory compliance.

• Collaborate with clinical and administrative teams to identify and vet new post-acute providers as needed to expand the network or address gaps in care.

Management of Letters of Agreement (LOA) for Placement:

• Oversee the development, negotiation, and management of LOAs for patient placements in post-acute settings, ensuring that terms align with the healthcare system’s financial and operational goals.

• Ensure LOAs include clear expectations around care standards, reporting requirements, and performance metrics, fostering accountability with post-acute care providers.

• Regularly review and update LOAs to reflect any changes in care protocols, regulatory requirements, or reimbursement models.

Policy and Procedure Updates for Centers for Medicare & Medicaid Services (CMS) Compliance:

• Lead the development, implementation, and regular updating of policies and procedures related to post-acute care services, ensuring alignment with CMS Conditions of Participation and other federal, state, and local regulatory standards.

• Work closely with compliance and legal teams to ensure adherence to all regulatory and accreditation requirements, addressing any areas of risk or non-compliance promptly.

• Serve as a resource for clinical staff and case managers, providing guidance on post-acute care policies, CMS regulations, and compliance best practices to ensure consistency across the system.

EDUCATION:

Bachelor of Science in Nursing (BSN) or Master of Social Work (MSW) required.

CERTIFICATION & LICENSURE:

ACM-Accredited Case Manager

TYPICAL EXPERIENCE:

6 years recent relevant experience

SKILLS AND KNOWLEDGE :

• Expert level clinical knowledge in the area of care management principles as they relate to population health as typically acquired during 5-7 years of experience in senior level clinical management.

• Comprehensive knowledge of Centers for Medicare and Medicaid Services (CMS) Conditions of Participation related discharge, including other federal and state regulations related to case management, social work, etc., across the care continuum.

Expertise in Post-Acute Care Services:

• In-depth knowledge of the full continuum of post-acute care services, including skilled nursing facilities (SNFs), inpatient rehabilitation facilities (IRFs), home health care, hospice, and long-term care.

• Understanding of complex care needs for diverse populations, including the elderly, those with chronic conditions, and patients requiring palliative care or rehabilitation.

• Experience with transitional care planning, addressing both medical and social determinants of health to ensure continuity of care across settings.

Healthcare System Leadership:

• Multi-facility management experience, overseeing post-acute care services across several hospitals or regions, including the ability to standardize processes, align goals, and ensure consistent quality of care.

• Proven ability to drive strategic initiatives at a system level, including collaboration with hospital executives and leadership teams across multiple facilities.

• Change management skills to lead organizational initiatives, improve care transitions, and ensure alignment of post-acute care with overall system objectives.

Regulatory and Compliance Expertise:

• Extensive understanding of federal, state, and local regulations governing post-acute care, including Medicare and Medicaid guidelines, Conditions of Participation (CoP), and accreditation standards (e.g., Joint Commission).

• Ability to develop policies and procedures to ensure regulatory compliance across multiple sites, mitigating risks and ensuring adherence to quality standards.

Data-Driven Decision Making:

• Proficient in leveraging data analytics to monitor key performance indicators (KPIs) such as readmission rates, LOS, patient satisfaction, and post-acute care utilization.

• Ability to develop and use dashboard tools for tracking outcomes, measuring the effectiveness of care transitions, and identifying opportunities for process improvements across the system.

• Experience in collaborating with IT teams to optimize electronic health record (EHR) systems and ensure integration with post-acute care providers for seamless care coordination.

Relationship Building and Collaboration:

• Skilled at establishing and maintaining strong partnerships with external post-acute care providers, including SNFs, IRFs, home health, and hospice agencies.

• Ability to negotiate and manage contractual relationships with external providers to ensure high standards of care and alignment with hospital and system goals.

• Excellent interpersonal skills to foster collaboration between acute care hospitals and post-acute care providers, ensuring alignment on care plans and the safe transition of patients.

Communication and Education:

• Effective at providing clear communication with clinical teams, hospital administration, and external stakeholders to align on care goals, expectations, and strategies.

• Ability to educate and train staff across the healthcare system on best practices in discharge planning, care transitions, and compliance with post-acute regulations.

• Skilled in developing patient and family education programs to ensure understanding of post-acute care services and patient engagement in their own care.

Quality and Performance Improvement:

• Strong background in quality improvement initiatives, particularly around care transitions and post-acute care outcomes.

• Ability to lead system-wide efforts to improve care coordination and reduce fragmentation of care, utilizing evidence-based practices to optimize patient outcomes.

• Experience with Lean, Six Sigma, or other performance improvement methodologies to streamline post-acute processes and eliminate inefficiencies.

Job Shift:

Days

Schedule:

Full Time

Days of the Week:

Monday - Friday

Weekend Requirements:

Occasionally

Benefits:

Yes

Unions:

No

Position Status:

Exempt

Weekly Hours:

40

Employee Status:

Regular

Sutter Health is an equal opportunity employer EOE/M/F/Disability/Veterans.

Pay Range is $94.32 to $150.90 / hour

The salary range for this role may vary above or below the posted range as determined by location. This range has not been adjusted for any specific geographic differential applicable by area where the position may be filled. Compensation takes into account several factors including but not limited to a candidate’s experience, education, skills, licensure and certifications, department equity, training and organizational needs. Base pay is just one piece of the total rewards program offered by Sutter Health. Eligible roles also qualify for a comprehensive benefits package. ​