Supervisor, Care Transitions-Portage Medical Center

Under direction of the Market Manager, Care Transitions and Rehab, the Supervisor of Care Transition will manage day to day operations of their site and/or area. The Supervisor will act in two capacities; the liaison between site and/or area leadership and the Care Transitions team and the content expert for all team clinical operations at their site (including TCC, PCN and SW).Supervisors will drive site specific metrics tied to Care Transitions including but not limited to NSOC, observation hours, length of stay, patient throughput, patient flow, readmission prevention efforts, follow up appointment obtainment and tracking as well as daily escalation of barriers. In addition, will focus on patient experience and staff engagement outcomes at their site and/or area.This role requires expert working knowledge of the roles and responsibilities of each team member and ability to be the content expert on all clinical operations for the Care Transitions team at their site and/or area.Collaborates with other disciplines at their site and/or area to maximum patient experience and throughput.

• Day to day oversight and support of the Care Transitions team (TCC and SW).
• Collaboration with physicians, homecare ambassadors, post-acute facility liaisons, UM, ACO/Population Health to ensure a smooth transition of care for patients while utilizing in-network providers. Focus on connection to our UH and JV network providers.
• Identifying trends, outliers, functional/technical needs, and improvement strategies to decrease length of stay and increase patient experience.
• Monitoring metrics to track performance of Care Transitions team and the selection of the right next site of care.
• Identifying and escalating barriers in collaboration with site specific leadership.
• Providing guidance/consultation/escalation to team regarding complex psychosocial and/or discharge planning issues/barriers.
• Regular meetings with local hospital and/or area leadership and other key stakeholders to review key metrics and team performance. Participation in hospital committees as assigned.
• Monitors regulatory compliance with CMS: DNA, IMM letters, audits, ABN, HINN LONC, etc.
• Coordinates activities to ensure patient’s appeal rights under Notification of Hospital Appeal Rights. Including timely answers to KeyPro phone calls regarding appeals and guidance to team/patient/family regarding complex family appeals.
• Development of team; clinically and professionally by providing career development and coaching opportunities.
• Develops and maintains audit processes in alignment with CMS conditions of participation and UH specific policy.
• Develops and participates in special projects and system committees tied to Care Transitions metrics.
• Under the guidance of the Regional Manager, will conduct talent selection, provide operational and practice oversight, complete performance evaluations, provide a just culture during corrective action, and if needed complete team member termination for direct reports.
• Assists with recruitment, orientation, mentoring, on-boarding and connection of new staff to other professional colleagues.
• Oversight of guidelines, policies and processes specific to Care Transitions team.
• Coordinates daily schedule for Care Transitions team, ensuring coverage for patient care units/physician teams.
• Maintains competencies and licensure for staff members in collaboration with System Care Transitions Educator and Regional Manager.

• Performs other duties as assigned.
• Complies with all policies and standards.
• For specific duties and responsibilities, refer to documentation provided by the department during orientation.
• Must abide by all requirements to safely and securely maintain Protected Health Information (PHI) for our patients. Annual training, the UH Code of Conduct and UH policies and procedures are in place to address appropriate use of PHI in the workplace.

• Bachelor's Degree from an accredited school of Social Work. (Required) or
• (ADN) Associate's Degree in Nursing or higher nursing degree (Required)

• 2+ years of clinical experiences (acute care and/or post-acute care management, case management or social work). (Required) and
• Hospital/Health agency experience. (Preferred)

• Must exercise creativity and problem-solving skills with the ability to communicate effectively with both internal and external clients. (Required proficiency)
• Confident, motivated self-starter and demonstrate flexibility and initiative. (Required proficiency)
• Computer and reporting skills. (Required proficiency)
• Critical thinking and problem solving. (Required proficiency)
• Decisive judgement. (Required proficiency)
• Ability to multi-task and prioritize work. (Required proficiency)
• Works autonomously. (Required proficiency)
• Communicates effectively with persons of various background (oral and written). (Required proficiency)
• Maintains clinical competency regarding health care delivery/case management/regulatory requirements. (Required proficiency)
• Leadership skills. (Required proficiency)
• Teaching skills. (Required proficiency)
• Maintains a calm, professional demeanor when dealing with internal and external contracts, customer focused, and ability to handle stress. (Required proficiency)

• Registered Nurse (RN), Ohio and/or Multi State Compact License Upon Hire (Required) or
• Licensed Social Worker (LSW) in the State of Ohio Upon Hire (Required) or
• Licensed Independent Social Worker (LISW) in the State of Ohio Upon Hire (Required) or
• Licensed Independent Social Worker Supervisor (LISW-S) in the State of Ohio Upon Hire (Required)

• Standing Frequently
• Walking Frequently
• Sitting Rarely
• Lifting Frequently 50 lbs
• Carrying Frequently 50 lbs
• Pushing Frequently 50 lbs
• Pulling Frequently 50 lbs
• Climbing Occasionally 50 lbs
• Balancing Occasionally
• Stooping Frequently
• Kneeling Frequently
• Crouching Frequently
• Crawling Occasionally
• Reaching Frequently
• Handling Frequently
• Grasping Frequently
• Feeling Constantly
• Talking Constantly
• Hearing Constantly
• Repetitive Motions Constantly
• Eye/Hand/Foot Coordination Constantly

• 10%