Job Description

Position Summary:

The Post-Acute Care Coordinator RN plays a key role in improving care transitions for Medicare patients by managing discharges from acute or post-acute facilities and ensuring patients receive appropriate, timely follow-up care. This position is integral to achieving CMS-aligned goals, such as reducing readmissions, improving quality scores, and enhancing the patient experience across the continuum of care.

Key Responsibilities:

• Coordinate discharge planning from hospitals or skilled nursing facilities (SNFs) to home or other care settings.

• Ensure timely scheduling of follow-up appointments and home care services in accordance with CMS guidelines.

• Monitor patients throughout their post-acute journey using internal ACO care tracking systems.

• Collaborate with providers, patients, and caregivers to ensure understanding of post-discharge instructions and care plans.

• Identify and escalate care barriers that impact quality or outcomes.

• Conduct on-site and virtual visits with SNFs, home health agencies, and provider offices.

• Provide onboarding and education to practices and facilities on care coordination protocols and quality initiatives.

• Support CMS initiatives related to transitional care management (TCM), 3-day SNF waiver, and patient engagement.

• Maintain accurate documentation in internal care platforms for audit and reporting purposes.

• Adhere to all HIPAA, regulatory, and organizational compliance standards.

Qualifications:

Required:

• Minimum 2 years of experience in a skilled nursing facility, home health, hospital discharge planning, or provider relations.

• Valid and unrestricted driver’s license with reliable transportation.

• Proficiency in using technology platforms for care coordination and communication.

• Proficiency in Microsoft Excel and Data Analysis .

Preferred:

• Bachelor’s degree in Nursing, Health Administration, or a related field.

• Knowledge of CMS ACO programs and transitional care processes .

• Experience working in a value-based care or ACO setting.

Skills & Competencies:

• Strong interpersonal and communication skills.

• Independent problem-solving ability.

• Highly organized and detail-oriented.

• Comfortable with remote work and flexible scheduling.

• Commitment to delivering high-quality, patient-centered care.

Travel Requirements:

• Must be able to travel locally and regionally ( up to 50%) for in-person meetings and site visits within the surrounding San Marcos area.

Salary & Benefits:

Salary: $70,000 per year (commensurate with experience)

Benefits Include:

• Competitive health, dental & vision insurance

• 401(k) retirement plan with company match

• Stock options opportunities

• Paid Time Off (PTO) and paid holidays

• Paid parental and bereavement leave

• Remote work flexibility and mileage reimbursement

• Company-issued technology and ongoing training support

Advanced Management USA is an equal opportunity employer and drug-free workplace. All employment is contingent upon successful completion of a drug screen, background check, reference verification, health assessment, and credential/license verification.

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