Director of Transitional Care and Clinical Development

SWING BED PROGRAM

Leadership, Care Management & Program Performance Expectations

Director of Transitional Care & Clinical Development + Care Manager

Program Identity: Transitional Care First

CCMSD's program is a Transitional Care Program that serves eligible patients under the Critical Access Hospital Swing Bed benefit. "Swing Bed" describes the regulatory and reimbursement mechanism; "Transitional Care" describes the patient experience, clinical purpose, and program identity. The program is designed to bridge the period between acute hospitalization and the patient's safest, most appropriate next destination-most often home-through skilled nursing, rehabilitation, interdisciplinary care coordination, patient and caregiver preparation, and deliberate transition planning.

The central program expectation is not simply to maintain Swing Bed census. It is to accept appropriate patients, establish meaningful recovery and transition goals, actively advance each patient toward those goals, remove barriers, prepare the patient and caregiver for the next level of care, and execute a safe, timely transition. Census growth and responsible utilization support the sustainability of that mission.

1. Purpose and Operating Model

The CCMSD Transitional Care Program is designed as a coordinated transitional-care program with clear ownership across the full patient and program cycle. The Director of Transitional Care & Clinical Development has administrative ownership of the program. The Care Manager has primary day-to-day ownership of patient progression after admission. These roles are complementary, not duplicative, and are expected to function as a tightly coordinated team.

DIRECTOR: OWNS THE PROGRAM

CARE MANAGER: OWNS PATIENT PROGRESSION

Builds, leads, grows, standardizes, measures, and protects the Transitional Care Program. Owns referral development, incoming referrals, census strategy, authorization systems, compliance infrastructure, QAPI, and program development.

Coordinates the admitted patient through the program. Owns day-to-day care management, IDT coordination, utilization/continued stay, discharge planning, patient/family communication, and transition execution.

2. Director of Transitional Care & Clinical Development - Primary Expectations

• Maintain administrative ownership and overall accountability for the CCMSD Transitional Care Program.

• Maintain real-time awareness of census, available capacity, anticipated admissions, expected discharges, and active referral opportunities.

• Actively develop referral relationships and maintain a sustainable referral pipeline; serve as the primary organizational contact for incoming Swing Bed referrals.

• Coordinate each referral from inquiry through clinical/operational review, payer requirements, acceptance or denial, transfer arrangements, and admission.

• Develop and maintain standardized payer authorization, financial-clearance, utilization, policy, regulatory, documentation, and contingency workflows.

• Monitor regulatory requirements, maintain survey/audit readiness, identify compliance gaps, and coordinate corrective action and education.

• Maintain program-level oversight after admission, including utilization, payer requirements, length of stay, discharge barriers, and anticipated bed availability.

• Lead referral-source development, strategic clinical/program development, QAPI, dashboards, performance reporting, and improvement initiatives.