Post Acute Care (PAC) Continuum Specialist

SUMMARY OF RESPONSIBILITY:

The Post-Acute Care Continuum Specialist (CCS) is responsible for ensuring the continuity of patient care in the post-acute setting (skilled nursing facilities) utilizing the appropriate resources within the parameters of established contracts and patients’ health plan benefits. The PAC-CS facilitates continuum of patients’ care utilizing nursing knowledge, experience and skills to ensure appropriate utilization of resources and patient quality outcomes. The PAC-CS performs care management functions on-site and/or telephonically. Coordinates and manages care to meet multiple service needs of members, ensures continuity of services and overcomes fragmentation of care and services.

ESSENTIAL FUNCTIONS:

• Utilizes the population health concept of a home first approach ensuring appropriateness of admission and efficient discharge to home with support services.

   

• Conduct prospective, concurrent, and retrospective review of active patient care on-site or telephonic, where assigned. Review patients' clinical records to ensure appropriate level of care within 48 hours of SNF admission. Review patient referrals within the specified CM policy time frame.

   

• Participates in weekly multi-disciplinary team meetings as needed.

• Coordinate provisions for discharge from facilities, including follow up appointments, home health, social services, transportation, etc., in order to maintain continuity of care.

• Educate patients and caregivers about preventive care, medical issues, and use of prescribed medical treatments and/or medications.

• Develops and maintains documentation of individual plan of care based on patient’s health assessment.

• Acts as a liaison between the patient, the PCP, and skilled nursing facility staff.  Maintains regular contact with the patient’s PCP.  Advocates on the behalf of the patient to identify the most appropriate institutional or community resources, SDOH barriers and assists in closing the gaps.

• Uses, protects, and discloses patients’ protected health information (PHI) only in accordance with Health Insurance Portability and Accountability Act (HIPAA) standards.

• Identifies resources in the Trinity Health services continuum.

• Assesses the member’s status on a weekly basis and works collaboratively with the skilled nursing facility to ensure goals of care are being met, barriers to discharge are identified early and SNF LOS is managed. Provide transitional care management services, including telephonic care management, for a 30-day period post SNF discharge.

   

• PAC-CS will be responsible for tracking key metrics including days of utilization and readmissions.

• Participates in addressing quality issues including readmission review meeting with Skilled Nursing Facility and Hospital Case Management.

• Other duties as assigned

The duties listed above are intended only as illustrative of the various types of work that may be performed. The omission of specific statements of duties does not exclude them from the position if the work is similar or a logical assignment to the position.

QUALIFICATIONS AND COMPETENCIES:

• Valid, unrestricted license in the state of practice, as an LPN/RN; graduate from an accredited program in professional nursing. Five years’ clinical experience and three years managed care experience.

   

• Valid Driver's license, travel requirements 25%

• Local Travel Required; Primarily to cover the Northern half of THONE geography (Hartford and Springfield)

   

• Case Management experience is strongly desired.

   

• Experience with geriatric population, geriatric condition management and Advanced Illness Care.

   

• Demonstrates effective team behavior, supporting other team members and working to support achievement of team objectives.

   

• Understands relevant accreditation and licensing requirements in assignments.

   

• Ability to be non-judgmental regarding living and health-related decisions.

   

• Ability to work with members and families with diverse opinions and diverse religious and cultural ideas and values.  Ability to work autonomously with little direction and be directly accountable.

   

• Possesses a working knowledge of available community resources or willingness to learn.

• Possesses a working knowledge of basic computer software

   

  PHYSICAL AND MENTAL REQUIREMENTS:

  The Physical demands and work environment characteristics described here are representative of those that must be met by an employee to successfully perform the essential functions of the job.  Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

   

• Ability to work long hours – over eight in a work day, and over 40 in a work week as necessary;

• Regularly required to use hands to finger, handle or feel objects, tools, or controls; reach with hands and arms; and talk or hear. 

• Frequently is required to walk and sit. 

• Occasionally required to stand; climb or balance; and stoop, kneel, crouch or crawl. 

• Ability to lift and/or move up to 20 pounds. 

• Vision abilities required by this job include close vision, color vision, peripheral vision, depth perception and ability to adjust focus. 

• The dexterity necessary to utilize a computer keyboard on a regular basis is essential.