Post Acute Care Coordinator (Onsite)

Summary:

The Post-Acute Coordinator supports the operational and administrative functions of the Post-Acute Care Program within an Accountable Care Organization (ACO). This role plays a vital part in ensuring smooth transitions of care between hospitals and post-acute providers such as skilled nursing facilities (SNFs), home health agencies (HHAs), and rehabilitation centers. Working under the Director of the Post-Acute Program Manager, the coordinator helps track patient transitions, supports communications with care partners, maintains documentation and reports, and contributes to overall program goals around reducing readmissions, improving outcomes, and enhancing care coordination.

Key Responsibilities:

Track hospital discharges and admissions to post-acute facilities using care coordination platforms (e.g., CarePort, HIE Alerts). Maintain updated records of partner facilities, user access, and care team assignments. Assist in the scheduling and coordination of partner check-ins, weekly huddles, and training sessions. Provide administrative support to the Post-Acute team, including meeting notes, data entry, and document preparation. Help prepare reports on program performance metrics, including readmission rates, ED alerts, and disease cohort outcomes. Support the onboarding process for new post-acute care partners and internal users. Monitor and support data collection related to Social Determinants of Health (SDOH), including housing instability, food insecurity, and transportation needs. Coordinate internally with ACO care managers, population health teams, and data analysts to ensure program alignment. Participate in quality improvement activities to support value-based care initiatives. Maintain and grow relationships with our preferred Post-Aute network.

Performance Metrics:

Maintain 95%+ accuracy in tracking logs and dashboards. Complete >90% of outreach within 24 hours of a Post-Acute setting admission. Complete > 90% of patients' follow-ups within 72 hours of discharge. Contribute to > 5% annual reduction in 30-day readmission rates for post-acute patients. Support improved provider performance scores toward ACO benchmarks.

Qualifications:

Associate or bachelor's degree in healthcare preferred. 1-2 years of administrative experience in a healthcare setting Proficiency in Microsoft Office (Excel, Outlook, Word) Excellent organizational and time-management skills Strong written and verbal communication abilities Ability to multitask and work collaboratively in a fast-paced environment

Preferred:

Experience in post-acute care settings (SNF, HHA, rehab, etc.) Familiarity with ACOs, value-based care, or population health Experience using care coordination platforms (e.g., CarePort, Epic, or similar)

Computer Skills:

MS Office Productivity Tools (Word, Excel, Outlook, PowerPoint), SQL, Power BI, SSRS, relational databases and other related software/technology.