The Director of Care Transition Coordination oversees the daily operational and logistical processes for transition planning (discharge planning) for social work, care navigation and behavioral health services across the Middle Georgia Region to include Atrium Health Navicent Medical Center, Atrium Health Navicent Baldwin, and Atrium Health Navicent Peach hospitals. The Regional Director of Care Transition Coordination serves as a subject matter expert on transitions of care and patient throughput for the region and beyond. Ensures that the coordination and arrangement of post-acute services by the Care Transitions team are conducted in a manner that is patient-centered, efficient, and cost-effective. Assures all necessary resources are available to effectually conduct transition/discharge planning and care pathway management. Assures appropriate monitoring systems are in place to provide continuous monitoring and documentation of transition planning activities to include referrals to community-based services and resources and placement of patients requiring post-discharge care at skilled nursing, rehab, behavioral health, and long-term acute care facilities. Performs duties with a sense of urgency and in alignment with our operational metrics of Experience, Efficiency, and Quality & Safety. Maintains the knowledge and skills necessary to provide care to patients and oversight of the Care Navigation team.
Major Responsibilities:
Provides oversight to the Care Transitions team in relation to discharge planning and care pathway functions and activities. Duties include the establishment of work schedules, ensuring employees work within Atrium Health’s pay practices, performs performance evaluations in a timely and appropriate manner, etc. while ensuring alignment with current clinical standards, and the day-to-day execution of programmatic operations. Works collaboratively with others through assessment of patient learning needs and discharge planning, designing, implementing, and continuously evaluating case management activities and processes.
Keeps current on state, federal, and payor requirements and regulatory guidance affecting the discharge planning process and communicates changes in requirements to the staff. Participates in internal and external compliance audits.
Assists staff with problem solving and resolution of problems and issues related to placement, community resources, and home care services. Able to provide guidance on situations that are difficult to manage. Able to discuss care pathways with Physicians, APPs, and staff to ensure appropriate management in a patient and organizational centered manner that optimizes throughput.
Provides leadership in the development and revision of departmental policies, procedures, work instructions, and protocols. Orients new staff and ensures continuing education of all departmental staff. Supports staff development and performance management; maintains focus on key needs, expectations, and enterprise initiatives.
Serves as primary departmental contact and liaison to community-based resources, including referral facilities/agencies which may be utilized by patients discharged from the facility. Regional representative on probate court petitions and hearings.
Identifies issues within processes to ensure optimum flow and success. Provides leadership and guidance to the team in process improvement initiatives. Stays abreast of new innovations and trends in the areas of care coordination, evidence-based practice, utilization management, and service excellence. Disseminates information and focuses the efforts of the organization on skills required and critical milestones for advancing outcomes-focused care throughout the region and beyond.
Provides leadership in the development and monitoring of key metrics to ensure success. Can determine root cause and formulate action plans to support success.
Provides adequate communication cascading to keep the staff fully informed of initiatives, expectations, and enterprise-wide experiences. Is open to communicate with staff and fosters and encourages a safe environment in which staff can freely verbalize issues and concerns. Provides feedback of action-based suggestions to the staff.
Develops evidence-based programs and initiatives which promote optimal quality of care and improvement of patient transitions, maximizes growth, and enhances revenue opportunities.
Leads and supports patient experience initiatives that drive top decile performance in patient satisfaction from a behavioral health perspective showing evidence of efforts to drive continuous improvement.
Works in conjunction with behavioral health senior leadership, medical director, colleagues, and physicians to set and achieve appropriate goals and strategies of the Behavioral Health service line.
Education
Bachelor of Science in Nursing
Certification / License
Registered Nurse in Georgia or a Compact License
Work Experience
Ten years of experience in progressive management positions within an acute hospital setting, with a minimum of five years’ experience in an implicit discharge planning or clinical case management position.
Knowledge / Skills / Abilities
Proficiency in medical terminology, clinical assessment, and diagnostics skills.
Knowledge of the DRG process and payment methodology for various federal, state, and commercial payers. Concurrent coding skills. Skill in identifying problems and recommending solutions. Skills in preparing and maintaining records and written reports. Skill in establishing and maintaining effective working relationships with physicians, hospital staff, and vendors. Ability to interpret, adapt and apply guidelines and procedures. Ability to analyze complex clinical scenarios and apply critical thinking. Extensive knowledge of reimbursement systems. Extensive knowledge of Federal, State and payer-specific regulations and policies pertaining to documentation and coding. Working knowledge of federal and state benefits and entitlements. Must possess experience in discharge/transition planning and thorough understanding of rules and regulations related to transition planning/placement services. Knowledge of community resources and case management is required. Working knowledge of CMS regulations and rules of participation. Familiarity and working knowledge of Best Practices relative to Medicare compliance (DNV CARF Joint Commission).
Physical Requirements and Working Conditions
Must be able to use visual acuity to monitor screen, computer, and hard copy materials. Must be able to hear and verbally communicate in person and over the phone or radio. Must be able to sit for prolonged periods of time (up to 2 hours). Must be able to comprehend and learn the operation of various office equipment. Must have functional range of motion of the cervical, thoracic, and lumbar spines, upper and lower extremities with a grip strength of 50-60# specific to job evaluation. Must be able to forward reach, overhead reach, bend, squat, kneel and apply proper body mechanics during the transfers and transport supplies and/or equipment using proper body mechanics. Must be able to lift up to ten lbs. specific to job evaluation.