This is a fully remote position, open to applicants in New York.

📋 Description

• Oversee and enhance the 30-day transition process from admission and discharge notifications through visits, escalations, and follow-ups.

• Expand medication reconciliation, durable medical equipment (DME), home health, primary care physician (PCP) and specialist scheduling, transportation, and caregiver assistance.

• Mentor distributed Nurse Practitioners (NPs), Registered Nurses (RNs), and Medical Assistants (MAs).

• Establish protocols, documentation standards, quality assurance checks, and reporting mechanisms.

• Collaborate with product teams, engineering, and health plans to enhance readmissions, Patient Care Record (PCR) and Total Resource Cost (TRC)/Healthcare Effectiveness Data and Information Set (HEDIS) Stars measures, and program financials.

• Report directly to the Chief Clinical Officer.

⛳️ Requirements

• Proven leadership in transitions of care, post-acute, or care management operations.

• Experience in scaling or significantly enhancing a post-discharge program.

• Practical expertise in post-acute interventions.

• Background in clinical team training.

• Familiarity with performance measurement for health plan populations.

• Ability to create workflows in collaboration with clinicians and cross-functional teams in a growth-oriented environment.

• Clinical license is advantageous.

• Experience with home-based care, value-based care models, or Admission, Discharge, Transfer (ADT)/Health Information Exchange (HIE) workflows is a plus.