Director: Hospital Partnerships & Care Transitions

Title: Director, Hospital Partnerships and Care Transitions

Dept./Division: Systems of Care

Reports to: Senior Vice President – Systems of Care

Purpose: The Director for Hospital Partnerships and Care Transitions is a key role responsible for the driving the development and maintenance of collaborative relationships with hospital systems to enhance the discharge planning, care transitions, and ongoing community-based care of patients. This position will oversee the centralized intake unit to streamline and optimize patient intake processes, ensuring that services are coordinated efficiently and in a timely manner. The Director will provide clinical guidance to intake staff and extend this support to agency-based care teams, ensuring that care delivery is consistent, high-quality, and data-driven.

Essential Responsibilities

Build and Maintain Hospital Partnerships:

• Establish and nurture strong, collaborative relationships with hospital systems, discharge planners, and other healthcare providers to enhance care coordination and smooth transitions from hospital to community-based settings.
• Facilitate regular communication between hospital discharge teams, care managers, and community-based providers to ensure a seamless continuum of care, reducing readmissions and improving patient outcomes.
• Implement strategies to strengthen hospital partnerships, address gaps in care transitions and ensure that discharged patients are supported by appropriate community resources and services.

Oversee and Optimize Centralized Intake Unit:

• Manage and supervise the centralized intake unit, ensuring the timely processing of patient referrals, intake assessments, and coordination of services.
• Streamline intake processes to maximize efficiency, minimize wait times, and ensure that patients are quickly connected to necessary care and support services.
• Collaborate with other team leaders to ensure that intake functions align with organizational goals, including maximizing patient flow and optimizing resource allocation.
• Assume on-call crisis response as needed.

Provide Clinical Guidance and Supervision:

• Offer clinical oversight to intake staff, ensuring they have the knowledge and resources to conduct thorough assessments and make informed decisions about patient needs.
• Extend clinical support to agency-based care teams, guiding them in best practices for managing complex cases and facilitating smooth transitions from hospital to community care.
• Regularly assess clinical competencies across staff and teams, providing training and support as needed to ensure high-quality care delivery.

Data-Driven Performance and Quality Improvement:

• Utilize data to monitor and measure performance against key metrics, including hospital readmission rates, discharge success, and patient satisfaction.
• Implement performance improvement strategies based on data insights to drive better outcomes, improve operational efficiency, and ensure compliance with healthcare regulations and standards.
• Develop and oversee processes for tracking and reporting key performance indicators (KPIs), ensuring that all teams are aligned with organizational goals and service delivery standards.

Key Skills and Qualifications:

• Proven experience in hospital care coordination, discharge planning, and community-based care systems.
• Strong leadership and supervisory skills, with the ability to manage and guide both intake staff and field-based care teams.
• Understanding of healthcare data and performance metrics, with experience using data to drive operational and clinical improvements.
• Clinical expertise and ability to provide guidance on complex care cases, ensuring patient-centered care throughout transitions.
• Strong communication and relationship-building skills, particularly in fostering partnerships with hospital systems and community-based providers.
• Experience in process optimization, particularly in the areas of patient intake, care coordination, and service delivery.

Minimum Education & Experience Requirements:

• Master Level clinician (RN, LCSW, LPC, or equivalent) with a minimum of 3 years of experience in hospital partnerships, care transitions, or health systems management.
• Experience with care management software, data tracking systems, and performance monitoring tools.
• Strong commitment to improving health outcomes for vulnerable populations through collaborative partnerships and evidence-based practices.

Additional Information

Our core values of integrity, respect, maximizing the individual potential, maintaining a supportive work environment and being data informed allow us to provide effective, timely, equitable and people-centered services which is the key to positive health outcomes for those we serve.

This job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee. Other duties, responsibilities, and activities may change or be assigned at any time with or without notice.