Director, Post-Acute Care and Home Health (Population Health; Tufts)

Description

Description

About us:

Navvis is a leading population health company, driving performance in value-based care. As an operating partner to some of the country’s most innovative health systems, physician enterprises, and health plans, we provide solutions that accelerate the journey to value-based care. Our approach is market-based – we respect the unique needs of populations in each community, including access to care, culture, values, and capabilities. Together with our partners, we set a new national standard in healthcare performance that delivers the affordability, quality, access, and experience that all patients deserve.

Learn more at www.navvishealthcare.com

Department overview:

What if we routinely asked every person involved in providing or receiving care: "What matters to you and why?" How would understanding "what matters" enhance our ability to transform health in communities and strengthen the connective process, leading to deeper levels of interaction and integration? The Post-Acute team is a part of our larger Throughput team, where we are deeply passionate about understanding what matters to people to ensure the delivery of Real-Person Care. We create an ecosystem that builds a foundation for better physical, social, and emotional health. Our Care Solutions, Analytics, Implementations, Clinical and Business Operations, and Learning and Development teams work tirelessly in partnership with our clients and stakeholders in communities to address the real-life healthcare needs people have every day.

This role is based in the Boston region, working with Tufts Medicine.

As the In-Market Post-Acute and Care at Home Administrator, you will:

• Regularly review performance of Post-Acute Care Alliance members through quarterly scorecards (if applicable), ACO expenditure reports, claims data, and other reporting methods as available to understand each facility’s overall performance (including value-based payment models and other risk-based contracts).
• Review referral acceptance rates, denials and admissions to non-alliance members for trend analysis and improvement opportunities.
• Collaborate with VP, Care Continuum to achieve efficient communication across the continuum.
• Meet with each transitional care unit/skilled nursing facility in the PAC alliance, to create regular channels of interaction, communicate changes, review performance, and understand opportunities for improvement. Ensure mutually determined goals are on track for achievement.
• Identify performance gaps in the alliance overall, as well as at an individual facility level, and develop strategies with corresponding action plans to improve performance.
• Lead a team of Post-Acute Care associates supporting patients in the transitional care unit/skilled nursing facility and post-acute care programs to ensure proactive discharge planning and coordinated care management. Assist in complex case planning and collaboration. Escalate performance concerns with facilities as indicated.
• Ensure collaboration between PAC associates and other stakeholders for a streamlined process that allows for the most efficient management of patients.
• Work across transitional care unit (TCU)/skilled nursing facility (SNF), home health partners, and internal stakeholders to advance clinical capabilities in the TCU/SNF Alliance, to care for an increasingly complex patient mix.
• Work with internal Navvis and key client teams to ensure inpatient rehabilitation facilities and home health network are adequately serving the needs of the population.
• Collaborate with other key Navvis teams to ensure a coordinated approach to care delivery. Including meeting regularly with appropriate stakeholders that intersect with post-acute and Care at Home performance, such as hospital care management, ambulatory care management, value-based care programs leads, health plans, geriatric programs, etc. to relay SNF Alliance and Care at Home performance to ensure the optimization of outcomes.
• Annually, and as indicated, review overall alliance composition related to performance and collaboration. Provide recommendations for changes to the alliance membership as indicated.
• Provide regular report-outs to internal and external teams to allow visibility into post-acute and Care at Home performance.
• Participate in national PAC and Care at Home administrative meetings on a quarterly basis to collaborate and share best practices.
• Other duties as required.
• Travels up to 80% to facilities and locations within the Boston market

A day in the life:

• As part of the Na