Serves as the liaison between the hospital and the post-acute network (PAN) skilled nursing facilities. Manages and facilitate communication between the inpatient care managers, external care providers and outpatient care managers for patients transitioning in and out of the acute care setting and post-acute programs. Assist the transition of patients to post-acute programs and eventually back to their primary care physician (PCP) and community.

Monitors, collects and analyzes data to evaluate the effectiveness, safety and quality of patient care in the post-acute care network programs. Reviews readmissions, analyzes root causes, develops and implements action plans. May participates in quality, readmission and oth...