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

📋 Description

• Develop the care pathway from the point of admission/discharge notification through the 30-day period, incorporating risk stratification, prompt in-home/virtual visits, escalation processes, and follow-up procedures.

• Implement medication reconciliation, durable medical equipment (DME), home health services, primary care provider/specialist scheduling, non-emergency medical transportation (NEMT), caregiver support, and social-needs interventions into consistent workflows.

• Create protocols, training materials, documentation standards, and quality assurance processes for distributed clinical staff.

• Collaborate on Admission, Discharge, Transfer (ADT) and Health Information Exchange (HIE) feeds, workflow tools, and performance metrics.

• Enhance readmission rates, Patient-Centered Medical Home (PCR) and Total Resource Cost (TRC)/HEDIS Stars performance, intervention completion rates, health plan return on investment (ROI), and payer confidence in the model.

• Establish a new post-discharge service line.

• Influence the clinical model, expand an existing clinical team, and be accountable for outcomes for Medicare Advantage, Medicaid, and Exchange members.

• Report directly to the Chief Clinical Officer.

⛳️ Requirements

• Experience in developing and launching a post-discharge, transitions-of-care, or readmission-reduction program, followed by scaling and enhancing it.

• Familiarity with post-acute care interventions in practice.

• Capability to convert health-plan economics, Transitional Care Management (TCM) documentation, and quality metrics into operational processes.

• Proven experience in leading distributed clinical teams.

• Ideally possess experience in home-based care, virtual care management, payer care management, or post-acute care environments.

• Hands-on experience as a cross-functional builder.

• Directors who are ready to advance to a VP role are strongly encouraged to apply.