Post Acute Care Surveillance Specialist (Hybrid - Troy, MI) - Populance

GENERAL SUMMARY:

Under the direction of the manager of PAC Surveillance is an integral member of the Value Based Care team, working with the purpose to improve health outcomes via access to services, detailed coordination when care is transitioning from one facility to another and/or from a facility to home. Develops positive working relationships with preferred status Skilled Nursing Facilities and Preferred status Home Health Care agencies. Responsible for tracking multiple and varied process measures for quality assurance and regulatory purposes.

PRINCIPAL DUTIES AND RESPONSIBILITIES:

• Maintains appropriate documentation of contacts, communications, coordination efforts and activities, interventions and outcomes.
• Utilizes payer and ACO data to coordinate transitions of care for health plan enrollees. Utilizes designated points of contact and positive relationships with Skilled Nursing Facilities and Home Health Care agencies to ensure these ACO member facilities are providing the required and agreed upon levels of service to ACO patients.
• Updates medical record data as appropriate.
• Extract data, perform appropriate verification, and provides reports to providers/clinical designee as requested, including ACO Preferred Providers and
  Facilities beyond the spectrum of traditional HFHS staff and facilities.
• Promotes collaborative teamwork within a multidisciplinary environment.
• Collaborate with and maintain open communication with all departments, ACO providers and ACO facilities as appropriate and facilitates excellent continuity of care.
• Communicates, collaborates and coordinates with customers, internal and external.
• Utilizes self-motivation, open minded thinking and a process and systems approach to the team's work to improve effectiveness. Utilizes critical thinking to problem solve.
• Adapt to change fluidly as the ACO Surveillance rapidly grows and expands its volume.
• Attends provider meetings as scheduled and participates as a multi-disciplinary member.
• Performs other related duties as assigned.