Post Acute Care Manager

Job Description

Job Description

Job Description

Job Title: Post Acute Care Manager

Department: Network Development Team

Reports To: Director of Home Health & Therapy

FLSA Status: Exempt

DISCLAIMER:

Job descriptions are not meant to be all-inclusive, and/or the job itself is subject to change. Nothing in this job description restricts management's right to assign or reassign duties and responsibilities to this job at any time.

Summary:

The Post-Acute Care Manager is responsible for overseeing patient transitions from inpatient settings to post-acute care providers such as skilled nursing facilities (SNFs), inpatient rehabilitation facilities (IRFs), home health agencies (HHAs), and hospice. This role ensures high-quality, cost-effective, and coordinated care across the continuum, supporting improved patient outcomes, reduced readmissions, and overall performance in value-based care programs such as ACOs.

Key Responsibilities

• Care Coordination
  1. Oversee transitions of care for patients discharged from hospitals into post-acute settings.
  2. Collaborate with case managers, providers, SNFs, HHAs, and families to develop and implement care plans.
  3. Monitor patient progress and facilitate timely discharges from post-acute facilities.
• Network & Provider Management
  1. Develop and maintain relationships with preferred post-acute providers to ensure high-quality, efficient care delivery.
  2. Track utilization and quality outcomes of network facilities, escalating concerns when needed.
  3. Assist with network development through strategic relationship building with post-acute facilities and agencies.
• Performance & Reporting
  1. Monitor length of stay (LOS), readmissions, and cost per member per month (PMPM) in post-acute settings.
  2. Use tools such as CarePort or similar platforms to provide real-time data and actionable insights.
  3. Track and report key performance indicators (KPIs) to the Directors of Home Health & Therapy and Skilled Nursing
  4. Assist the Directors of Home Health & Therapy and Skilled Nursing in team management with oversight of Post Acute Transition Coordinators
• Quality & Compliance
  1. Ensure adherence to evidence-based practices, CMS guidelines, and value-based care requirements.
  2. Support care team huddles, case reviews, and audits to drive continuous improvement.
  3. Collect and verify counter-signed Business Associate Agreements (BAAs) and provider/user access (PEEP) forms from all partners; securely store them in the designated OneDrive Post-Acute folder and maintain a tracking log of receipt dates, storage paths, and any outstanding items.

KPIs for Post-Acute Care Manager

• Skilled Nursing Facility (SNF) Length of Stay (LOS)
• 30-Day Readmission Rate
• Preferred Network Utilization
• Cost per Member per Month (PMPM) – Post-Acute

Supervisory Responsibilities

Assists Directors in supervising Post-Acute Transition Coordinators and other assigned staff supporting post-acute initiatives.

Qualifications

Education & Experience

• Associate or Bachelor’s degree in Healthcare Administration, Nursing, Public Health, or related field required
• Minimum of 2–5 years of administrative experience in a healthcare setting
• Project management experience preferred
• Demonstrated success managing teams and performance
• Experience in post-acute care settings (SNF, HHA, rehab, etc.) and using care coordination platforms (e.g., CarePort, Epic, or similar)
• Familiarity with ACOs, value-based care, or population health preferred

Skills & Competencies

• 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
• Strong leadership and team management skills
• Excellent consulting and relationship management skills, with a proven ability to engage physicians and practice leaders.

Language Skills:

Ability to read and comprehend simple instructions, correspondence, and memos. Ability to write simple correspondence. Ability to effectively present information in one-on-one situations to visitors, clients, physicians, healthcare entities, leadership and other employees of the organization.

Reasoning Ability:

Ability to apply common sense understanding to carry out detailed but uninvolved written or oral instructions.

Computer Skills:

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

Other Skills and Abilities:

• Commitment to confidentiality, integrity, and professional ethics
• High integrity, confidentiality, and professional judgment

Physical Demands:

While performing the duties of this Job, the employee will have a combination of standing, sitting, bending, and reaching. May work at a computer monitor for prolonged periods. The employee may lift and/or move up to 10 pounds.