*Candidates for this position must have ACO knowledge and CM experience.

Purpose:

Ensures coordination and continuity of care through effective transitions of care management as patients move in and out of the acute care environment.

Primary Duties:

Identify high risk patients by utilizing a standardized risk stratification process Develop preliminary transition plan with anticipated disposition, including contingency plan Collaborate with hospitalist and other key team members to manage transition of care activities and communicate vital information Actively participates in daily transition rounds Identify transition barriers and collaborate in comprehensive, patient-centered care plan development. Submitting nursing orders as needed, to assure timely transitions. Coordinate patient access to necessary services, including community and public health resources. Drives the transition process. Ask probing questions on progress (e.g. facility search, patient teaching, facilitate testing) Collaborate with care team to provide discharge/transition education. Serve as an essential link for patients without a primary physician. Work in partnership with acute and ambulatory care team to follow patient through care continuum and provide thorough hand-over Coach for self-management utilizing motivational interviewing Facilitate post-acute appointments as applicable Ensure timely documentation of all patient encounters Maintain positive working relationships with all key customers Attend applicable conferences, trainings and meetings Participate in quality improvement and strategic initiatives Complete special projects and other duties, as assigned