Job Description

Description

Job Profile Name: Medical Director, Transitional Care

Company: Oak Street Health 

Title: Medical Director, Transitional Care

Location: Candidates can be located in New York City, Northern NJ, Philadelphia, OR Detroit

Company Description

Oak Street Health is a rapidly growing, innovative company of community-based healthcare centers that provides higher quality health and wellness care that improves outcomes, manages medical costs, and provides an unmatched experience for adults on Medicare in medically 

underserved communities.  By providing holistic, comprehensive and integrated care right in our patient's communities, we can keep our patients healthy and then reinvest cost savings in further care for those same communities and others. Since 2013, Oak Street Health has brought its singular approach to tens of thousands of people in Illinois, Indiana, Michigan, Pennsylvania, and Ohio.  At 40 locations, and with an ambitious growth trajectory, Oak Street Health is attracting and cultivating team members who embody Oak Street values and are passionate about the mission to rebuild healthcare as it should be.

For more information, visit http://www.oakstreethealth.com. 

Role description: 

Oak Street Health’s Transitional Care program is focused on facilitating interdisciplinary collaboration and care continuity across care settings and systems, empowering the patient and/or caregiver to play an active and informed role in post-hospitalization care plan execution. The program supports patients attributed to Oak Street Health for primary care and those attributed to CVS Healthspire’s Risk Bearing Entity (RBE) for care management support.

The Medical Director of Transitional Care is responsible for leading the Transitional Care Providers in completing in-home Post-Discharge Visits, as well as providing programmatic support to national OSH/RBE medical management and transitional care leadership and staff. The Medical Director provides leadership in executing the Transitional Care program goals which include ensuring high-quality, patient-centered care; preventing avoidable readmissions; and managing efficient resource utilization and improving patient and provider satisfaction. 

Responsibilities: 

• Serving a national Subject Matter Expert on Transitions of Care 

• Leading multi-state Transitional Care Provider teams, including the oversight of daily operations, monitoring team/individual performance and coaching staff when appropriate, supporting positive team culture and professional development of teammates, providing coverage and support as needed.   

• Modeling clinical excellence, compassionate patient-centered care, care model adherence, and success in metrics

• Ensuring teams are providing great clinical care to complex patients according to defined pathways within the patient’s home, including relentless follow-through with home health, specialists, social workers, hospitals, SNFs, and specialists to prevent avoidable hospital readmissions

• Understanding, teaching and implementing clinical guidelines at both the individual provider and market level

• Ensuring teams are providing an Unmatched Patient Experience, ensuring patients are delighted with the level of care they receive, and providing service recovery as needed

• Supporting providers in implementing best-in-class daily and weekly interdisciplinary team meetings and patient care after hospital admission

• Ensuring market operations are running smoothly and safely on a daily basis, including ensuring there is adequate staffing each day, arranging coverage for any call-offs or scheduled PTO, ensuring scheduling and billing processes are executed efficiently, ensuring that all Standard Operating Procedures are followed

• Leading the implementation of operational initiatives, including training the team on new initiatives and workflows. 

• Providing direct or supporting efforts in the hiring, training, and mentoring of Transitional Care Providers in new and existing markets 

• Assisting the OSH/RBE Department of Medical Management in the development, execution and improvement of the Transitional Care program 

• Helping all OSH/RBE markets resolve specific needs as related to Transitional Care navigation 

• Executing effective collaboration between multi-disciplinary teams including but not limited to: OSH/RBE Care Navigation, Utilization Management,  health system facilities, local care teams and patient/family 

• Having firm knowledge and executing CMS, state-specific and NCQA compliance criteria as related to Transitional Care 

• Monitoring OSH data related to patient cost, admissions, post-discharge appointment completion and health outcomes to help guide to help direct Transitional Care program initiatives and goals 

Leadership and Culture:

• Building relationships with care teams. Acknowledge and celebrate successes of care team members and communicate opportunities for improvement

• Creating and maintain a culture of coaching up and growth of providers and care teams. 

• Listening to feedback from care team members and address concerns with constructive problem-solving

• Conducting performance reviews and discuss provider goals and help develop plans to achieve these goals

• Cascading both programmatic information to care team members as well as escalating care team concerns and ideas to program leadership.

• Advocating for program, care teams, and patients

• Supporting a positive, Oaky culture of joy in practice

• Being an ambassador to corporate and center-based field leadership by building relationships with regional leadership to grow program awareness, scope and coverage

• Leading and drive cross market projects, as assigned

• Acting as an ambassador in the local social/community organizations, as needed

• Other duties, as assigned

Ideal candidates have: 

• M.D., D.O., or APRN

• Board certification in Internal Medicine or Family Medicine required for M.D. or D.O.  Board certification in Family, Adult, or Gerontology for APRN.

• Experience in clinical leadership roles, leading and coaching providers to be the best they can be for their patients and their colleagues

• Experience using a metrics-driven approach to the provision of medical care and/​or quality projects 

• Experience successfully driving teams towards achievement of metrics

• Experience with Google Suite; working knowledge of Microsoft Office Product Suite 

• 3+ years of experience in outpatient practice preferred

• 2+ years of experience in transitional care preferred

• Fellowship training in Geriatrics, other professional degrees (e.g., M.B.A., J.D., M.P.H.), and prior executive roles welcomed but not required

• Knowledge of Medicare/Medicaid and NCQA regulatory Transitional Care criteria 

• Strong clinical and assessment skills 

• Outstanding verbal and written communication skills 

• Ability to work independently and maintain flexibility in a fast-paced environment 

• Ability to analyze data and use it to improve care delivery 

• Self-starter with a high level of accountability and responsibility for the outcome of care 

• Highly organized and able to manage multiple priorities appropriately 

• Independent problem-solving skills 

• Able to work collaboratively and build enduring relationships with providers, patients and the multidisciplinary team. • A flexible, positive attitude 

• Valid driver's license and ability to travel daily 

• US work authorization 

• Someone who embodies being "Oaky" 

What does being "Oaky" look like? 

• Radiating positive energy 

• Assuming good intentions 

• Creating an unmatched patient experience 

• Driving clinical excellence 

• Taking ownership and driving for results 

• Being scrappy 

Why Oak Street? 

Oak Street Health offers our coworkers the opportunity to be at the forefront of a revolution in healthcare, as well as: 

• Collaborative and energetic culture 

• High levels of responsibility and rapid advancement 

• Headquarters (the "Treehouse") located in the heart of Downtown, close to many public transit options and great restaurants 

• Competitive benefits; including paid vacation/sick time, generous 401K match with immediate vesting, as well as health benefits 

Oak Street Health is an equal opportunity employer. We embrace diversity and encourage all interested readers to apply to oakstreethealth.com/careers.

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