Director of Care Coordination

Now Hiring Director of Care Coordination Regional Green Bay and Fox Valley Market

In your new role, you will serve as a dedicated brand ambassador, showcasing the comprehensive continuum of care that North Shore provides. You will have the unique opportunity to build meaningful connections by meeting new referrals at the bedside before their transition, ensuring a personalized and seamless experience. Working collaboratively with facility teams, Central Intake, and Directors of Care Coordination, you will play a vital role in streamlining care and fostering strong professional partnerships.

The Post-Acute Director of Care Coordination is responsible for supporting high-quality, coordinated transitions of care from the acute care setting to skilled nursing facilities (SNFs), home health, hospice, outpatient therapy, or other post-acute care environments. The Care Coordinator collaborates with interdisciplinary teams, patients, families, and post-acute providers to ensure safe, timely, and appropriate transitions that reduce avoidable readmissions and improve patient outcomes.

• Identify and develop relationships with health systems, hospitals, physicians, senior retirement communities and skilled nursing facilities
• Meet with referral sources to build strong partnerships and gain knowledge of the needs of the referring partner
• Serve as a liaison between hospital, SNFs, assisted living, home health agencies, hospice and other post-acute providers
• Facilitate referrals to North Shore Health systems by gathering medical and financial data, meeting with patients and families, as well as working with facilities to transition patients to home
• Conduct chart reviews and risk stratification to identify patients requiring complex discharge planning
• Monitor post-acute care pathways to ensure alignment with evidence-based protocols and patient goals
• Participate in operational meetings to share updates on referral development, progress towards monthly targets and provide feedback from referral sources and the community at large
• Facilitate timely communication between providers and care teams during transitions of care
• Provide referral / Intake support and education to post-acute providers to ensure continuity of care and adherence to treatment plans
• Track patient progress post-discharge and follow up on care milestones, including therapy participation, medication reconciliation, and follow-up appointments
• Monitor for early signs of deterioration or gaps in care and intervene to prevent unnecessary readmissions
• Assist with advanced care planning discussions and documentation, when appropriate
• Participate in performance improvement initiatives related to transitions of care, quality metrics, and value-based care programs (e.g., ACOs, BPCI-A)
• Collect and analyze post-acute care data to identify trends, gaps, and opportunities for improvement
• Serve as a resource and clinical educator for SNF partners on post-hospitalization care standards, documentation best practices, and care coordination
• Other Tasks as assigned
• Safety knowledge:
  Know and follow North Shore Health rules, follow North Shore Health dress and hygiene policies, demonstrate proper use of equipment, report equipment needs or repair, follow North Shore Health smoking policies, use required protective equipment (as needed during center visits), follow infection control standards, policies and procedures
• Resident Rights:
  Know Resident Rights, help the residents/patients exercise and/or protect their right, maintain confidentiality of resident/patient and employee information
• HIPAA:
  Follow and adhere to North Shore Health’s policies and procedures implementing HIPAA requirements for the privacy and security of protected health information, use and/or disclose only minimum amount of Protected Health Information necessary to complete assigned task, report all suspected violations of company’s HIPAA policies or procedures to North Shore Health Compliance Department

The responsibilities of this position may involve significant travel and physical activities including standing, occasional lifting (up to 50 pounds unassisted), bending, stooping, pushing, pulling, and twisting. All employees when visiting centers may be required to provide lifting and transfer assistance to residents. Lifting and/or transferring some residents will require use of a lifting device and/or assistance from other staff.

• Registered Nurse (RN) license in good standing (state-specific) (preferred)
• BSN required; MSN or case management certification preferred
• Minimum of 3 years of experience in acute care, post-acute care, case management, or care coordination
• Knowledge of Medicare guidelines, SNF level of care, PDPM, Home Health PDGM and value-based care models preferred
• Strong clinical assessment skills and ability to engage in complex discharge planning
• Excellent communication, collaboration, and patient advocacy…