Under the supervision of the Associate Director of Post Acute and Care at Home Programs (MD/DO), the Advanced Practice Provider - Transitions of Care is responsible for direct patient care for low-income and uninsured patients in post-acute environments as appropriate, including Skilled Nursing Facilities (SNFs), and the Care at Home program (home visits). The Advanced Practice Provider Transitions of Care will work in conjunction with Nurse Case Managers, Social Workers, Community Health Workers, Physicians and other care team members to provide transitions of care/navigation services, working in collaboration with inpatient care teams and other Central Health medical and case management teams. This position models a commitment to the organization’s vision/mission/values to support an unparalleled patient experience and positive clinical outcomes.

Essential Duties
• Provide direct patient care to patients in SNFs and acute hospital settings.
• Collaborate with the medical management and case management team to oversee transitions of care at home program with home visits.
• Collaborate with attending physician to provide care at SNFs.
• Participate and lead quality and care review meetings for patients in the post acute program.
• Facilitate collaboration with partner organizations to ensure the provision of compassionate, and effective care coordination for hospitalized patients and medical care to other patients in post-acute settings who require medical service.
• Work in close consultation with the patient’s primary care provider and other licensed health care facility provider to deliver medical care of MAP patients while admitted in post-acute environments in the best interest of the patient and consistent with Central Health’s policies, mission and goals.
• Communicate effective information to patients, families, colleagues, nursing and other health care professionals, as appropriate.
• Prepare and provide necessary timely and accurate reports and forms, as may be required by Central Health or facility in the performance of medical services.
• Coordinate care with skilled nursing facility team members and other Physicians and Advanced Practice Providers to eligible patients in skilled nursing facilities.
• Plan and coordinate care daily with all members of Central Health’s care team to assure maximum quality and efficiency of care between Eligible Patients, Physicians, Advanced Practice Providers, case management and nursing.
• Perform medical and administrative services under general guidance and minimal supervision with accountability for specific organizational-level goals.
• Work closely with families of diverse patient populations.
• Facilitate effective communication with Case Management/Care Coordination teams regarding readmission prevention.
• Proactive collaboration to facilitate discharge teaching for readmitted/high risk patients prior to or at discharge.
• Develop and execute the planning, implementation and evaluation of service delivery, patient experience, and care management activities.
• Prioritizes duties and responsibilities, demonstrating strong organization and time management skills.
• Demonstrates excellent verbal and written communication skills, assuring appropriate confidentiality is always maintained.
• Interacts with others in a positive, professional manner, contributing to a positive team environment.
• Performs other duties as assigned.

Knowledge/Skills/Abilities:
• Directly affect improvements in patient well-being through accurate and timely diagnosis and delivery of relevant, high quality medical care.
• Ensure all tasks provided and associated with patient care, patient administrative processes and related duties comply with all regulatory and accreditation standards including The Joint Commission and Central Health Standard Operating
Procedures, Policies and Procedures.
• Ability to collaborate with team of professionals to achieve specific goals.
• Ability to thrive in a complex and dynamic work environment with multidisciplinary, cross-functional teams and matrixed team structures.
• Demonstrated ability to manage and prioritize multiple complex projects with varying deadlines and limited resources.
• Ability to apply critical thinking to generate and assess potential solutions and to anticipate needs in advance.
• Ability to manage competing objectives in an ambiguous, fast-moving environment to achieve results.
• Knowledge of best practice and industry standards for Advanced Practice Providers.
• Compliance with data confidentiality and security procedures.
• Ability to manage employees and interact with colleagues in a respectful, supportive fashion which encourages employee’s personal and professional growth.
• High level skill at building relationships within the organization and with external partners.
• Able to balance a customer-oriented and results-driven approach.
• Able to persuade others to approach topics and ideas differently.
• Strong attention to detail and accuracy.
• Ability to communicate complex ideas clearly and effectively through both writing and speaking.
• Experience with electronic medical records and healthcare-derived data and a working knowledge of the laws and regulations that govern the same; and
• Demonstrated ability to perform complex operations in Microsoft Office Suite.
• Ability to collaborate with patients, families and care teams through multiple complex systems.
• Strong assessment skills.
• Follows standard precautions.
• Maintains confidentiality.
• Exhibit compassion, vulnerability, and empathy when working with employees (patients) and advancing Central Health’s DEI and health equity goals.
• Provide patient centered care that is inclusive and focuses on cultural humility.
• Share a commitment to diversity and inclusion awareness and practices across Central Health.
• Complete all mandatory training and maintain appropriate credentials/licensure

MINIMUM EDUCATION: Graduation from an accredited School of Physician Assistants OR Master’s degree from an accredited School of Nursing.

PREFERRED EXPERIENCE:
• Experience with Epic and training or support for Epic end user programs.
• Knowledge of medical care and management of patients in SNF and other transitions of care facilities.
• Demonstrated knowledge of Joint Commission standards, HIPAA regulations, Quadruple Aim, and Value Based Care.

REQUIRED CERTIFICATIONS/LICENSURE: Holds and maintains these certifications as a professional. Lapsing/expiration of these certifications/licensure will result in suspension of work:
• Unrestricted license to practice as a Physician Assistant in the State of Texas OR unrestricted license to practice Nursing in the State of Texas/current credentialing as an Advanced Nurse Practitioner by the Texas Board of Nurse Examiners.
• Current certification in area of specialty.
• Current Drug Enforcement Agency (DEA) for the purpose of writing prescriptions.
• Current Healthcare Provider Cardiopulmonary Resuscitation (CPR) through American Heart Association.
• Current Basic Life Support Certification for Healthcare Providers through American Heart Association.

REQUIRED COURSES/COMPLETIONS (e.g., CPR):
Basic Life Support (BLS) - Obtained through approved American Heart Association or Red Cross.
Advanced cardiovascular life support (ACLS)-obtained through approved American Heart Association or Red Cross