Continuum of Care Coordinator

Job Description

Job Summary 

The Continuum of Care Coordinator (CCC) oversees the continuum of care in assigned markets for the MSSP ACOs ensuring that patients receive the highest quality of care while responsibly managing Medicare resources. The CCC is responsible for managing patient transitions between hospitals, clinics, and post-acute care providers. They conduct group and individual meetings with hospital leadership and post-acute administrators promoting timely access to appropriate levels of quality care while working to reduce readmissions, avoidable hospital services, length of stay and home health recertification. The CCC builds strategic relationships in the community with the goal of enhancing patient health and well-being and reducing healthcare costs. The CCC monitors data and presents to hospital leadership to identify trends in resource utilization and serves as a local subject-matter expert (SME) on all things ACO for their supported markets. 

Essential Functions

• Develops, maintains, and coordinates the Post-Acute Care Collaborative for assigned markets, serving as the primary liaison between collaborative partners and hospital leadership to ensure continuity of care. Updates the Collaborative based on ACO Scorecard data and CMS performance metrics.
• Tracks discharge patterns for Medicare patients, collaborating with hospital and post-acute care teams to support ACO benchmarks through education, data sharing, and planning efforts.
• Monitors metrics, identifies trends, and utilizes data to support improvement in care quality for ACO patients. Recommends actionable steps to hospital leadership to help the market meet CMS benchmarks and reduce avoidable costs.
• Collects and communicates information on successes and barriers to the Payment Innovations team, supporting the development and evaluation of strategic plans for ACO performance improvement.
• Maintains current knowledge of ACOs and value-based care programs impacting Medicare patients, providing expertise to assist with reimbursement strategies and alignment with CMS benchmarks.
• Prepares and shares ACO scorecard data with primary care provider groups and facilitates discussions with providers and practice leaders in coordination with the PPS Quality team.
• Performs other duties as assigned.
• Complies with all policies and standards.

Qualifications

• Associate Degree in Nursing or Healthcare Management required
• Bachelor's Degree in Healthcare Administration or related field preferred
• 2-4 years of strong clinical or healthcare experience with a focus on hospital discharge planning, utilization management, and case management required
• Previous experience as a Care Navigator for high-risk patient populations preferred

Knowledge, Skills and Abilities

• Demonstrates strong knowledge of pre-acute and post-acute care resources, care transitions, and healthcare utilization management.
• Proficient in data aggregation and analysis, with the ability to present ACO performance metrics effectively.
• Strong interpersonal and communication skills to collaborate with multidisciplinary teams and external stakeholders.
• Advanced proficiency in Google Suite and Microsoft Excel for reporting and data management.
• Possess a high level of organizational and problem-solving skills to manage multiple priorities in a dynamic environment.
• Demonstrates attention to detail and the ability to interpret and apply CMS benchmarks and regulations.

Licenses and Certifications

• RN - Registered Nurse - State Licensure and/or Compact State Licensure preferred

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