Director, Transitions of Care

The Director, Transitions of Care will be a leader on Aledade’s product development team with responsibility for leading surveillance of existing product uptake and cross-functional development, testing and iteration of new tech-enabled products, workflows and process improvement related to acute and post-acute transitions of patient care. Aledade is committed to improving patient care through increased coordination between ACO physicians and their patients during episodes of increased medical acuity and transitions of care.

Our technology platform guides primary care practices through workflows that support better patient outcomes, such as through real time event notifications and enabling post-discharge primary care appointments. The Director will collaborate with Aledade’s clinical leadership, provider networks, technology, and analytics teams to optimize and support the work of this  technology platform and local field teams. The position reports to the VP, Transitions of Care and High Risk.  

The ideal candidate for this role will have experience working with acute and post-acute providers and/or primary care in value-based arrangements or health care change management. Specific experience managing episodes of care or bundled payment programs is beneficial. The Director will share our passion for improving the health of the U.S. population and our respect for the role of primary care providers in that mission.  An understanding of how to design and optimize tech-enabled workflows and performance reporting will be key to success in this position. The job will require persistence, teamwork, listening skills, stakeholder engagement (including primary care practices) and strong project management capabilities. 

Role & Responsibilities:

  • Implement and refine the integration and prioritization of Aledade’s ACO interventions for patients in care transitions in support of savings-focused strategic plans
  • Intense focus on leveraging performance metrics to inform focus of product iteration and refinement of adoption approaches
  • Develop tactical plans to optimize practice workflows and execution approach of  targeted interventions, including, but not limited to, Transitional Care Management, Emergency Department Follow-up, and short term Skilled Nursing Facility stays
  • Clearly define recommended roles, responsibilities, and workflow for Aledade partner practice physicians and clinical staff anchored by Aledade’s technology platform and practice EHRs
  • Directly collaborate with adoption and training teams to develop and maintain related curriculum and other content-based artifacts that articulate literature-based best practices and Aledade’s point of view, owning development of initial drafts
  • Collaborate with technical product manager in a two-way product development process to build tech-enabled solutions 
  • Coordinate with broader product development team to ensure cohesive initiative strategy
  • Identify areas where potential external partnerships would lead to greater success
  • Own Initiative scoping, phased rollouts, technology implementation
  • Engage practice teams to ensure a user-centered design process
  • Summarize tactical plans and project status to leadership team, and escalate blockers as appropriate


Qualifications / Considerations: 
  • Clinical experience preferred (APN, PA, RN, SW)
  • Demonstrated ability to re-engineer practice or provider workflow, preferably in value-based initiatives or other practice transformation efforts
  • Deep understanding of the acute to post-acute eco-system and incentive structure
  • Success in matrixed organizations, ability to coordinate across domains while staying focused on overarching objectives
  • Ability to evaluate current state and chart path to future vision, including roadmapping or sequencing intermediate steps, agile product development experience is a plus
  • Demonstrated ability to use data to assess opportunities and measure progress
  • Proven ability to understand the drivers of adoption and practice success and overcoming typical barriers to change
  • Experience building and/or implementing tech-enabled solutions to practice workflow problems
  • Proven ability to span from high level strategy to hands-on implementation and basic project management skills 
  • Unique perspectives on how to change healthcare delivery that may not fit into the mold of traditional models

At Aledade, we don’t just accept differences, we celebrate them. We strive to attract, develop, and retain highly qualified individuals representing the diverse communities where we live and work. Aledade is committed to creating a diverse environment and is proud to be an equal opportunity employer. Employment policies and decisions at Aledade are based on merit, qualifications, performance, and business needs. All qualified candidates will receive consideration for employment without regard to age, race, color, national origin, gender (including pregnancy, childbirth or medical condition related to pregnancy or childbirth), gender identity or expression, religion, physical or mental disability, medical condition, legally protected genetic information, marital status, veteran status, or sexual orientation

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