Practice Improvement Facilitator

Everyone Is a Caregiver

At UMass Memorial Health, everyone is a caregiver regardless of their title or responsibilities. Exceptional patient care, academic excellence and leading-edge research make UMass Memorial the premier health system of Central Massachusetts, and a place where we can help you build the career you deserve. We are more than 20,000 employees, working together as one health system in a relentless pursuit of healing for our patients, community and each other. And everyone, in their own unique way, plays an important part, every day.

Job Summary

Under the general supervision of OCI management, Manager of Post-Acute Networks, OCI is responsible for working with patients and families in helping them navigate their care needs across the continuum of care. The position involves supporting post-acute relations, monitoring clinical quality of post-acute partners, and working on clinical interventions with patients and providers for improved transitions of care in the Office of Clinical Integration.

I. Major Responsibilities

1. Responsible for the ongoing clinical oversight, patient outreach and navigation, and monitoring for participating facilities and agencies that are members of our UMMACO post-acute network and the broader community of partners where we support quality improvement initiatives.

2. Utilizes a wide array of Post-Acute Tools to assist in the clinical management of patients across post-acute partners. Tools include : Epic, Salesforce, Tableau, CarePort (Insight, Guide, CM Referral Management), CMS Care Compare, OneNote.

3. Works with OCI Care Navigation / Post-Acute team members to strategize and ensure smooth transitions of care, guides patient and family care and navigation across the continuum of care from acute to post-acute and outpatient care (PCPs and specialists). - Develops and uses standardized care navigation workflows and templates to follow patients across settings, discuss and brainstorm patient cases to help remove barriers to discharge planning at SNF / IRF / LTACH. - Attends Medicare meetings with post-acute partners to review and guide patient cases, meet with patient and family to assist in discharge planning and goals of care. - Supports relations and connections with UMass Network constituents (hospital case management, physicians, and specialists). - Attends collaboratives to educate post-acute partners on an array of relevant topics including strategies for improved patient care, care transitions, community supports, clear clinical pathways, etc. - Contributes to refinements in clinical navigation workflows and tools for standard work.

II. Position Qualifications

License / Certification / Education : Required : 1. Current Massachusetts LPN or Registered Nurse licensure and registration 2. Five (5) years of experience, including three (3) years in a clinical post-acute setting, preferred. 3. Experience working in or interfacing with different post-acute provider types (e.g., SNF, HHA, Hospice). 4. Familiarity with transitions of care, case management handoff to range of post-acute settings, active outreach to patients and families in guiding care across the continuum.

5. Experience / knowledge of hospital / healthcare / post-acute delivery systems including electronic medical / health records, registration, scheduling, and billing systems.

Experience / Skills : Required : 1. Ability to use personal computers and select software applications, and proficiency with Microsoft Office applications. 2. Excellent interpersonal skills, including the ability to establish and maintain effective working relationships with physicians, administration, and staff. 3. Excellent verbal and written communication, organizational and project management skills also required. 4. Knowledge of customer service principles required. 5. Evidence of organizational quality improvement (QI) experience including : a. Experience collecting and analyzing key data with corresponding deployment of interventions to improve processes and outcomes. b. Demonstrated capacity to support process improvement (e.g., experience in successful systems improvement).