Nurse, Field Operations Coordinator, Skilled Nursing Facility - (Home Based in Salem, VA)

Medical/Healthcare Lafayette, Louisiana Salem, Virginia Roanoke, Virginia Reference ID: JR3664-POS015920


Join us at SCP Health in this Home-Based Field Operations Coordinator - Salem, VA!


The Field Operations Coordinator is responsible to support and lead SCPs enhanced post discharge (DC) services for patients from the acute setting. Primary responsibilities include managing the length of stay (LOS) for BPCI-A patients in the Skilled Nursing Facilities (SNF), monitoring readmissions from skilled nursing (SNF)/inpatient rehab (IRF)/ long term acute care (LTCH). Additional responsibilities include managing relationships with Home Health Agencies (HHA) and reporting patient outcomes to SCP physicians, hospital case management teams, and SCP BPCI-A operations team. Primary functions and expected results include: Completing daily tasks necessary to manage BPCI-A patients on site at facilities to ensure quality patient care and outcomes, managing appropriate length of stay (LOS), meeting determined BPCI-A goals for post-acute setting management, following all CMS guidelines, and adhering to SCP Health policies and code of conduct.


The Patient:

  • Identify patients qualifying into the BPCI-A program discharged to SNF
  • Minimum weekly visits to SNFs for utilization review meetings to follow patient progress in facility and face to face patient visits
  • Asses patients risk for readmission post DC from SNF/IRF/LTCH
  • Improve HH utilization post DC from post-acute settings
  • Follow all HIPAA and patient confidentiality guidelines

The Hospital and Post-Acute Facilities:

  • Creates Care Plan for each Post-Acute Facility
  • Develop relationships and work closely with hospital case managers, SNF administrators/Director of Nursing/Director of Rehab, HH administrators and serve as a liaison between SCP health and all providers/facilities for BPCI-A patients
  • Frequent on-site visits to SNF to attend IDT/UR meetings for BPCI-A patients to collaborate on patient progress toward DC to produce consistent patient outcomes and manage LOS for patient progression to next level of care
  • Facilitate utilization of post discharge home health through education for patient/families and ensure HHA receives appropriate information for successful transition to home
  • Serves on facility/hospital committees, if requested, and works with hospital groups to assist in systems integration and support care redesign and quality initiatives for BPCI-A

The Providers:

  • Educates HPS and HM Medical Director on patients who were discharged from their hospitals including current condition/outcome, facility cooperation levels, and patient/family/caregiver satisfaction
  • Assists SVP/GMO BPCI-A in educating HM hospital providers on appropriate next sites of care and use of preferred network to ensure enhanced positive outcomes
  • Engage in monthly meetings at with hospital HM providers to reinforce the above and provide continued feedback and education

The Operations Teams:

  • Updates internal bundle payment census daily with current information
  • Complete tracking spreadsheets weekly to report on patient status and progress toward discharge from SNF current location of bundle patients, post discharge facility engagement, HM/Hospital engagement
  • Identify and resolve obstacles to discharge from SNF to move patient to next appropriate level of care
  • Provides daily updates to supervisor on bundle patients inside next sites of care if they are not progressing as expected at next site of care
  • Communicates with Care Coordination Team on any active patients that transferred from home health into a Facility and coordinates resumption of care tracking with patient prior to discharge.
  • Provides feedback to SCP Health regarding status and reason of readmissions on any bundle patient from next sites of care whether it is from a SNF, LTAC, IRF, or Home Health
  • Inclusive of all duties listed above, but not exclusive of other duties as determined necessary for the success of the BPCI-A program

Knowledge, Skills, and Abilities:

  • Knowledge of BPCI-A program
  • Knowledge or education regarding SNF guidelines
  • Must demonstrate skills in Microsoft Office including Excel, Word, and Outlook

EDUCATION (Required and/or Preferred):

  • High School  Required
  • Associate degree Nursing - Required
  • Bachelor's Degree Preferred


  • 3-5 years of clinical experience as RN - preferably in role of case manager or in SNF
  • Experience in sales or working inside/alongside hospital/SNF/HHA based environment


  • Current state licensure as RN 
Remote Opportunity
Home Based Opportunity
Case Management
Case Manager