Harbor Health operates two Elder Service Plan Programs of All-Inclusive Care for the Elderly, a program that allows frail elders to live in their homes and communities. Our Elder Service Plan has two medical and day centers in Mattapan and Brockton, MA and cares for more than 580 participants. we are seeking a SkilledNursing Transitions Coordinator to join our team at the Elder Service Plan (a PACE Program) in Brockton.

Harbor Health offers an excellent, comprehensive benefits package including Health, Dental, Vision, Life, & Disability insurance, 403b Savings Plan, Generous Paid Time Off plus 11 additional Holidays and much more!

Role:

Under the general direction of the Director of Care Coordination, the Skilled Nursing Transitions Coordinator partners with the Interdisciplinary Team (IDT) to facilitate the progression of care for Harbor PACE Elder Service Plan (ESP) participants in short term rehabilitative, skilled nursing, and long-term acute care facilities. Using a collaborative approach, the Interdisciplinary Team focuses on delivery of efficient, high quality rehabilitative and skilled nursing care. The Care Transitions Case Manager ensures appropriate utilization of skilled nursing resources with a goal of safe and timely discharge for the Harbor ESP participants and navigates and utilizes ESP services to support effective transitions. Our ideal candidate must be adept at utilization review, care coordination, discharge planning, fiscal responsibility, and relationship development.

Responsibilities:

• Works in close collaboration with other members of the Interdisciplinary and Utilization Management team around all Subacute, Skilled Nursing Facility (SNF), and Long Term Acute Care (LTAC) transitions.
• Serves as a collaborative bridge between ESP and SNFs.
• Performs prospective, concurrent, and retrospective utilization management-related reviews and ensures all data are tracked, evaluated, and reported.
• Utilizes clinical skills to telephonically provide and facilitate utilization review, continued stay reviews and utilization management of all cases based on clinical experience and recognized guidelines.
• Collaborates with ESP interdisciplinary teams and subacute/skilled nursing facilities regarding management of members not meeting continuing stay criteria.
• Obtains and communicates clinical information effectively to participant, family/caregiver, Interdisciplinary Team and SNF/Subacute facility.
• Works collaboratively with Utilization Management Nurses and Care Coordinators to ensure facilities have all information and paperwork needed to care for the participant at the time of admission.
• Authorizes length of stay appropriate for condition and level of function and communicates to appropriate facility.
• Actively seeks clinical documentation and reviews all assessments and clinical information for every active SNF/Subacute/LTAC stay and ensures ESP has comprehensive Electronic Health Record (EHR) records.
• Supports different disciplines in overcoming barriers to discharge, including housing, functional needs, and caregiver support.
• Serves as conduit for family and home facility (e.g., ALF) communication for discharge planning.
• Develops trusted relationships with SNFs, including attending meetings and routine site visits to contracted facilities.
• Maintains tight control of active SNF/LTAC caseload, knows goals to discharge, barriers, etc., escalates issues on team meetings, follows action items to completion and supports IDT members needing access to SNF information.
• Facilitates All-Teams SNF weekly utilization review meetings with IDT including prepares and maintains meeting spreadsheets for effective meeting management, ensures action items are addressed, communicates planned discharge dates, sends updated authorizations and additional pertinent information as needed to respective SNF/Subacute facilities.
• Responsible for reviewing, close monitoring and authorizations for add-on charges for participants in long term care when appropriate.
• Responsible for obtaining the information necessary to assess a participant's clinical condition, identifies ongoing clinical care needs and ensures that participants receive services in the most optimal setting to effectively meet their needs.
• Ensures all services needed for safe discharge are in place including Home Health Aides/Caregivers, nursing, Durable Medical Equipment (DME), rehab, transportation, family, etc., ensures Discharge Summary with medication list is obtained and as appropriate, completes assessment tools and enters orders (e.g., DME, home health aides, etc.).
• Triggers Change of Status actions when participants are unable to return home.
• Conducts regular and as-needed in-person visits to contracted Skilled Nursing Facilities for relationship-building, resident visits, quality checking, etc.
• Uses Patient Ping to track participant disposition.

Requirements:

• Associate in nursing (ADN) required, BSN preferred or degree in other discipline as indicated by licensure (see substitutions)
• Current, valid, and unrestricted Registered Nurse (R.N.) license or other valid MA license as indicated in substitutions
• Substitutions for RN license:
  1. LPN (Licensed Practical Nurse) with 4 additional years of Skilled Nursing Facility experience
  2. Registered Physical or Occupational Therapist (PT/OT)
  3. OTA/PTA with 4 additional years of Skilled Nursing Facility experience.
• Current BLS (Basic Life Support for Health Care Providers) Certification
• Current, valid, and unrestricted MA Registered Nurse (R.N.) license.
• 2 years of experience in a Skilled Nursing Facility as Staff Nurse, Nurse Case Manager, Nurse discharge planner or clinical manager
• 2 years of experience working in geriatric care
• Experience with hospital discharge and/or home care experience preferred
• Proficient in Microsoft Office 365 skills to include in Word, Excel, Outlook and Teams, database use, Nursing Home Electronic Health Records, and data entry
• Demonstrated ability to run effective meetings - both virtual and in-person.
• Must be able to travel between two or more sites and to outside contract agencies in a timely manner.

All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability or veteran status.