• Collaborate with ACO partners to design, implement, and refine care pathways that improve patient outcomes and reduce unnecessary utilization. • Analyze post-acute care trends, SNF performance metrics, and readmission rates to identify opportunities for improvement. • Guidance of cross-functional teams in developing strategic initiatives that align with ACO goals and CMS benchmarks. • Facilitate stakeholder engagement, including clinical teams, care coordinators, and external providers, to ensure alignment and accountability. • Production of training materials, workflows, and toolkits to support care pathway adoption. • Leverage data analytics and visualization tools to communicate insights and drive strategic planning. • Stay current on regulatory changes, CMS guidelines, and industry best practices related to value-based care and post-acute management. • Review data trends from monthly claims files for assigned partners using Next Site of Care Dashboard. • Compare current data with KPIs to determine any course corrections needed (i.e. action plans). • Incorporate data findings into action planning meetings and report out on any care redesign initiatives in progress along with recommendations for other care redesign efforts supported by the data. • Review and prepare SOC action slides for Action Planning and JOC meetings. • Work with Partner Success and Clinical Consultants to determine Acute Care Redesign activities for success. • Conduct weekly patient management calls with In Network top 3 volume SNFs. • Engage with SNF and HHA interdisciplinary teams to perform care redesign. • Evaluate, build and maintain SNF and HHA performance networks. • Improve network utilization, discharge patterns and readmissions. • Coordinate and lead quarterly meetings with leadership at each performance top 3 volume facility/agency to report outcomes and recommend process improvements. • Collaborate with cross-functional team to communicate PAC interventions to partners. • Manage SNF LOS, Readmissions and Ensure Continuity of Care. • Work with PAC partners to help identify new value-based care patients entering their care and begin transitional care planning from admission. • Obtain weekly updates on patient status, transition challenges and anticipated discharge date and engage on challenges to ensure appropriate SNF length of stay. • Consistent, daily use of the technology (Clarity) platform.