**Location:** Avera Health **Worker Type:** Regular **Work Shift:** Day Shift (United States of America) **Pay Range:** _The pay range for this position is listed below. Actual pay rate dependent upon experience._ $30.75 - $46.25 **Position Highlights** **You Belong at Avera** **Be part of a multidisciplinary team built with compassion and the goal of Moving Health Forward for you and our patients. Work where you matter.** **A Brief Overview** Coordinates and implements actions to develop and maintain Avera's Continuing Care Network for post-acute care providers. Manages and coordinates integration of unaffiliated and affiliated providers with the goal of a seamless care continuum for Avera patients. Serves as clinical review, education resource for proactive management of patients included in value-based care programs. Serves as subject matter expert and liaison to partner sites as it deals with payer relationships for commercial and other managed governmental plans. **What you will do** + Establish infrastructure within Avera for continuing care network including performance metrics, measurement and reporting methodologies with a focus on clinical outcomes, patient experience and patient safety. + Establishes tools and programs to integrate affiliated and unaffiliated long term care facilities, including universal discharge form, care transitions, and care pathways that cross the acute-post-acute-community continuum. Assists in performance improvement activities for patient and transition of care to facility, community or home. + Proactively identifies and manages patients under value-based care programs for length of stay, readmission, emergency room. Implements, communicates and proactively works with facilities and care team to manage patients to the most appropriate level of care and coordinate with primary care and health system resources. + Establishes and maintains ongoing communications with Continuing Care Network members through regular meetings and communications focused on finding solutions to issues in discharge of patients from the hospital to post-acute and community settings and assuring evidence-based practices throughout the care continuum. + Provides leadership in care navigation best practices for value-based arrangements for Avera entities and the Continuing Care Network. + Serves as the liaison for Avera longer term care to Avera Payer Strategies + Establishes relationships and supports quality initiatives and projects across the continuum of care with Avera long term care, Avera@Home, Avera facilities for transitions of care. **Essential Qualifications** The individual must be able to work the hours specified. To perform this job successfully, an individual must be able to perform each essential job function satisfactorily including having visual acuity adequate to perform position duties and the ability to communicate effectively with others, hear, understand and distinguish speech and other sounds. These requirements and those listed above are representative of the knowledge, skills, and abilities required to perform the essential job functions. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential job functions, as long as the accommodations do not cause undue hardship to the employer. **Required Education, License/Certification, or Work Experience:** + Bachelor's in Social Work, Nursing or related field. + Registered Nurse (RN) - Board of Nursing An active license in the state of practice. Upon Hire or + Licensed Social Worker (LSW) - Licensing Board An active license in the state of practice. Upon Hire **Preferred Education, License/Certification, or Work Experience:** + • Proven knowledge and experience of post-acute/community care settings, including levels of care provided, regulatory requirements and third-party reimbursement systems. + • Proven skills in care continuum development and management, care transitions, care pathway development, integration of primary care and primary care management and utilization review in community care settings **Expectations and Standards** + Commitment to the daily application of Avera’s mission, vision, core values, and social principles to serve patients, their families, and our community. + Promote Avera’s values of compassion, hospitality, and stewardship. + Uphold Avera’s standards of Communication, Attitude, Responsiveness, and Engagement (CARE) with enthusiasm and sincerity. + Maintain confidentiality. + Work effectively in a team environment, coordinating work flow with other team members and ensuring a productive and efficient environment. + Comply with safety principles, laws, regulations, and standards associated with, but not limited to, CMS, The Joint Commission, DHHS, and OSHA if applicable. **Benefits You Need & Then Some** Avera is proud to offer a wide range of benefits to qualifying part-time and full-time employees. We support you with opportunities to help live balanced, healthy lives. Benefits are designed to meet needs of today and into the future. + PTO front-loaded for eligible hires + Free health insurance options, for full-time single coverage on Avera High Deductible Health Plan + Up to 5% employer matching contribution for retirement + Career development guided by hands-on training and mentorship _Applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, protected veteran status. If you are an individual with a disability and would like to request an accommodation for help with your online application, please call 1-605-504-4444 or send an email to_ _talent@avera.org_ _._ At Avera, the way you are treated as an employee translates into the compassionate care you deliver to patients and team members. Because we consider health care a ministry, you can live out your faith, uphold the dignity and respect of all persons while not compromising high-quality services. Join us in making a positive impact on moving health forward. The policy of Avera to provide opportunities for all qualified employees or applicants without regard to disability and to provide reasonable accommodations for all employees or applicants who may be disabled. Avera is committed to ensuring compliance in accordance with the Americans with Disability Act. For assistance, please contact HR Now at 605-504-4444. Additional Notices: For TTY, dial 711 Avera is an Equal Opportunity/Affirmative Action Employer: Minority/Female/Disabled/Veteran/Sexual Orientation/Gender Identity.