Summary:

The Continuum of Care Coordinator (CCC) is a valued member of the hospital leadership team. This individual will work hand-in-hand with multiple departments to improve the lives of patients attributed to the Accountable Care Organization (ACO), and monitor the ACO Care Continuum for patients discharged from ACO Hospitals; this includes managing the local partners in the post-acute network. The CCC will collaborate with Hospital Leadership and Case Managers to review trends in resource utilization and serves as a local subject matter expert on all things ACO for their supported markets.

Essential Duties and Responsibilities:

1. Collaboration with Case Management on appropriate and timely discharges to post-acute services.
2. Serve as a liaison between ACO hospitals and the Post-Acute Network.
3. Participate in readmission reduction efforts.
4. Works closely with the ACO vendor, the Corporate Payment Innovations team, other internal departments,
physicians, and Post-Acute Network members to drive performance outcomes in the ACO attributed
population.
5. Regularly updates hospital leadership on ACO performance.
6. Helps to set strategy for the market ACO efforts to drive positive performance.
7. Works closely with both the employed and independent physician participants in the ACO to identify
opportunities for improvement.
8. Provides education and serves a resource for all things ACO in the supported markets.
9. Establishes relationships with community resources to mitigate socioeconomic challenges and
communicates resources back to Case Management, PCPs, and others.

Qualifications:

Bachelors degree required, Master degree in relevant field preferred. A current, unencumbered Nursing or Social work license is desired. A Minimum of two years of strong clinical/healthcare experience required. Working knowledge of care transitions with specific emphasis on hospital discharge planning, utilization management, post-acute resources, case management and disease management. Understanding of pre-acute and post-acute venues of care and post-acute community resources, physician office routines, and transitional procedures for pre and post-acute care. Comfortable working with multiple key stakeholders on care delivery efforts. Ability to aggregate and present ACO performance data.

Education

• Bachelors or better

• Masters or better