Sr. Manager, Transitional Care

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As the nation’s leading health solutions company, we reach millions of Americans through our local presence, digital channels and more than 300,000 purpose-driven colleagues – caring for people where, when and how they choose in a way that is uniquely more connected, more convenient and more compassionate. And we do it all with heart, each and every day.

Company Description

Oak Street Health is a rapidly growing company of primary care centers for adults on Medicare in medically-underserved communities where there is little to no quality healthcare. Oak Street’s care is based on an entirely new model that is based on value for its patients, not on volume of services. The company is accountable for its patients’ health, spending more than twice as long with its patients and taking on the risks and costs of their care. For more information, visit  http://www.oakstreethealth.com.

Role Description:

The Director of Transitional Care is part of Oak Street Health’s national Transitional Care Leadership team and is responsible for leading the Transitional Care RN (TRN) cohort. OSH’s Transitional Care program supports multidisciplinary care across facility-based care teams, OSH care teams, utilization management, care navigation, and patients and caregivers. The Director provides leadership to TRN managers / leads responsible for ensuring high-quality, patient-centered care, preventing avoidable readmissions, efficient resource utilization, and maintaining high levels of provider, caregiver, and patient satisfaction.

Core Responsibilities:

• Serve as national leader for Transitional Care RN (TRN) cohort

• Serve as member of Transitional Care Leadership Team consisting of operational and clinical leaders responsible for overall program strategy and execution

• Monitor key performance indicators including medication reconciliation post-discharge (MRP), follow-up after ED visit (FMC), post-discharge visit (PDV) completion, SNF ALOS, etc. to guide TRN-specific and Transitions program-level goals

• Manage team of managers / leads who each manage TRN pods

• Indirectly manage daily operations, regional & facility assignments, caseloads, team and individual performance, and coaching via managers / leads

• Participate in and lead (as needed) inpatient and SNF rounds to facilitate proactive discharge planning in partnership with clinical leaders

• Direct and support hiring and training of TRNs in new and existing regions

• Develop training materials, complete quality audits, and complete process evaluations to inform systems and process enhancements

• Partner with regional clinical and operational leaders (S/RVP, R/SMD, PHD, RDO, etc.) to support Transitional Care performance locally

• Facilitate internal, cross-team collaboration among field teams, Population Health, Data, Product, Managed Care Operations, etc. proactively and frequently

• Proactively build external relationships with hospital and SNF case management, directors of nursing, hospitalist services, etc. to build systematic discharge planning and care coordination workflows

• Leverage knowledge of CMS, state-specific, and NCQA guidelines related to case management and transitions of care

• Other duties as assigned

What are we looking for?

• Master’s degree in healthcare including nursing, social work, public health, health administration, business administration with healthcare focus

• 2+ years direct supervisory experience

• 3+ years in an administrative position

• 5+ years in case management, transitional care, discharge planning, utilization management, and/or home health

• Active RN or LCSW license within one or more OSH states

• Case Management Certification (CCM) preferred

• Proficient with Microsoft Office, Google Suite, and healthcare EMRs

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