• Provide operational and clinical leadership across multiple value-based financial risk contracts, population health initiatives, and integrated care programs throughout AHS.

• Translate system strategy into executable workflows that align acute, ambulatory, and post-acute care coordination efforts.

• Provide direct leadership and oversight for approximately 28 Complex Care Coordinators and Post-Acute Care (PAC) Liaisons across inpatient, ambulatory, and post-acute settings.

• Partner with AMG and ACO leadership to implement strategic initiatives (e.g., Cardiometabolic Alliance) focused on high-risk and vulnerable populations.

• Lead post-acute care coordination strategy, ensuring strong command of PAC workflows, discharge pathways, and care transitions to Skilled Nursing Facilities (SNFs), Home Health, High performing networks, Hospice, and Palliative Care.

• Drive reduction in post-acute length of stay (LOS) through proactive care planning, early identification of barriers, and close collaboration with PAC partners.

• Partner with SNF medical directors, SNFists, community physicians, and post-acute leadership to align clinical goals, escalation pathways, and discharge readiness.

• Oversee PAC Liaisons embedded in high-volume SNFs, ensuring consistent engagement, timely patient follow-up, and alignment with AHS standards.

• Monitor and optimize PAC network performance, including utilization patterns, readmissions from SNF, ED transfers, and avoidable acute escalations.

• Collaborate with ACO and utilization management teams to support appropriate PAC placement, avoid over-utilization, and promote safe, timely transitions home.

• Design, implement, and continuously refine care delivery models that support value-based care across the continuum, with particular emphasis on post-acute optimization and transitions management.

• Ensure alignment with ACO contract requirements related to cost containment, quality metrics, and patient experience.

• Lead and support targeted initiatives (e.g., HTN pilot with CV Service Line) to reduce readmissions, improve throughput, and enhance post-discharge outcomes.

• Ensure high-risk patients with HRRP diagnoses (COPD, Pneumonia, AMI, CABG, CHF) receive timely, coordinated care across acute and post-acute settings to minimize CMS penalties and prevent avoidable readmissions.

• Exercise independent clinical and operational judgment on a daily basis, managing complex patient care scenarios, staff escalation issues, and cross-departmental challenges.

• Collaborate closely with AVNA Homecare & Hospice, Palliative Care, Mobile Integrated Health (MIH), and post-acute providers to ensure seamless transitions and patient advocacy.

• Serve as a key operational and clinical leader within the High-Performing Network, particularly in the PAC space.

• Ensure department priorities, workflows, and service standards are implemented consistently and effectively.

• Monitor utilization trends (ED, inpatient, SNF, home health), identify opportunities for improvement, and implement population-based interventions.

• Represent Care Coordination and PAC initiatives in meetings, committees, and presentations with hospital executives, physicians, and system leadership.

• Leverage analytics, dashboards, and performance reporting to guide care coordination strategy, PAC optimization, and return-on-investment evaluation.

Key Job Functions:

• Leadership: Provide strategic direction, influence stakeholders, and drive outcomes across the care continuum.

• Program Management: Design, implement, and sustain high-value care coordination and post-acute care programs.

• Process Improvement: Lead continuous improvement, conflict resolution, and staff development initiatives.

• Collaboration: Partner effectively with physicians, post-acute providers, healthcare teams, and community partners.

• Independent Judgment: Demonstrate sound clinical and operational decision-making with accountability for outcomes.

• Inclusivity: Foster an inclusive, collaborative culture across diverse teams and settings.

• Communication: Exhibit strong written, verbal, presentation, and active listening skills.

• Technical Proficiency: Proficient in Microsoft Office, including Excel; experience with care coordination platforms preferred.

• Additional Duties: Perform other responsibilities as assigned by the Executive Director.

Education:

• Graduate of an accredited Nursing Program; BSN required, CCM preferred.

• Licensure: Active NJ RN license required; PA and NY licenses preferred.

Experience:

• Minimum 5 years of management experience

• 7-10 years of RN experience

• Strong background in care coordination, transitions of care, post-acute care, utilization management, and population health preferred.