Specialist, Transition of Care, Remote



Bethesda, MD, USA
Posted on Wednesday, May 22, 2024
This role will work directly with Skilled Nursing Facilities (“SNF”) to coordinate the discharge plan for Aledade Accountable Care Organization (“ACO”) Patients and the connection back to their PCP in the community. This role will also contribute to designing the broader ACS SNF Transition of Care Program.

Essential Duties & Responsibilities:

  • Build and maintain relationships with SNF teams as the liaison from the local Aledade ACO
  • Build out the protocols and processes to manage Aledade Patients in SNF’s which includes developing the playbook to run the program (i.e. How to use the analytics platform to identify patients who may be ready for discharge, how to determine discharge recommendation, under which circumstances to escalate to the SNF, etc.)
  • Leverage patient-level data and population level analytics (including length of stay data) to prioritize patients for potential discharge and determine recommended care plans.
  • Lead data review meetings with key SNF staff including, but not limited to, reviewing patient panels at each SNF and discuss condition, length of stay, discharge options, and other key considerations for next steps of care; and, analyze data from technology platform partner to inform the recommendation in conversation with SNF
  • Develop relationships with Aledade practices, providing relevant information regarding their patients in SNFs, and escalating clinical concerns (as needed)
  • Other duties as assigned

Required Skills/Abilities:

  • Bachelor's Degree
  • Ability to maintain working relationships as an “account manager” to various skilled nursing facilities within Aledade Care Solutions ACO network
  • Ability to work autonomously, taking into consideration clinical and social factors to develop recommendations for transition of care plan for Aledade patients in SNFs
  • Basic knowledge of performance improvement concepts and EMR documentation
  • Experience working on cross-functional teams to execute complex projects
  • Working knowledge of Medical Diagnosis Coding
  • 3 years’ experience working in a value-based care environment

Preferred Skills

  • Experience working with post-acute care providers (including home care agencies and skilled nursing facilities) and other post-acute resources. Experience working with cross-functional teams to implement or refine programs
  • Clinical background (RN, LMSW, LCSW, PT/OT, or other), or deep expertise in skilled nursing facility transitions (i.e. admissions, administration)
Who We Are:
Aledade, a public benefit corporation, exists to empower the most transformational part of our health care landscape - independent primary care. We were founded in 2014, and since then, we've become the largest network of independent primary care in the country - helping practices, health centers and clinics deliver better care to their patients and thrive in value-based care. Additionally, by creating value-based contracts across a wide variety of payers, we aim to flip the script on the traditional fee-for-service model. Our work strengthens continuity of care, aligns incentives, and ensures primary care physicians are paid for what they do best - keeping patients healthy. If you want to help create a health care system that is good for patients, good for practices and good for society - and if you're eager to join a collaborative, inclusive and remote-first culture - you've come to the right place.
What Does This Mean for You?
At Aledade, you will be part of a creative culture that is driven by a passion for tackling complex issues with respect, open-mindedness and a desire to learn. You will collaborate with team members who bring a wide range of experiences, interests, backgrounds, beliefs and achievements to their work - and who are all united by a shared passion for public health and a commitment to the Aledade mission.
In addition to time off to support work-life balance and enjoyment, we offer the following comprehensive benefits package designed for the overall well-being of our team members:
Flexible work schedules and the ability to work remotely are available for many roles
Health, dental and vision insurance paid up to 80% for employees, dependents, and domestic partners Robust time off plan 21 days of PTO in your first year 2 Paid Volunteer Days & 11 paid holidays
12 weeks paid Parental Leave for all new parents
6 weeks paid sabbatical after 6 years of service
Educational Assistant Program & Clinical Employee Reimbursement Program
401(K) with up to 4% match
Stock options
And much more!
At Aledade, we don’t just accept differences, we celebrate them! We strive to attract, develop, and retain highly qualified individuals representing the diverse communities where we live and work. Aledade is committed to creating a diverse environment and is proud to be an equal opportunity employer. Employment policies and decisions at Aledade are based on merit, qualifications, performance, and business needs. All qualified candidates will receive consideration for employment without regard to age, race, color, national origin, gender (including pregnancy, childbirth or medical conditions related to pregnancy or childbirth), gender identity or expression, religion, physical or mental disability, medical condition, legally protected genetic information, marital status, veteran status, or sexual orientation.
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