Continuum of Care Coordinator

The Continuum of Care Coordinator (CCC) is a valued member of the hospital leadership team. This role will work hand-in-hand with multiple departments to improve the lives of patients attributed to the Accountable Care Organization (ACO), located in Texas. The CCC holds responsibility for managing the Post-Acute Collaborative Network for Lake Granbury Medical Center and Cedar Park Regional Medical Center and serves as a local subject-matter expert (SME) on all things ACO. Key responsibilities include, but are not limited to, the following:

• Collaboration with Case Management on appropriate and timely discharges to post-acute services.
• Serve as a liaison between Lake Granbury Medical Center/Cedar Park Regional Medical Center and the Post-Acute Network.
• Participate in readmission reduction efforts
• 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
• Regularly updates hospital leadership on ACO performance
• Helps to set strategy for the market ACO efforts to drive positive performance
• Works closely with both the employed and independent physician participants in the ACO to identify opportunities for improvement
• Provides education and serves a resource for all things ACO in the New Mexico markets
• Establishes relationships with community resources to mitigate socioeconomic challenges and communicates resources back to Case Management, PCPs, and others.

Skills:

• Must have a working knowledge of care transitions with specific emphasis on hospital discharge planning, utilization management, and post-acute resources
• Must be an effective communicator and collaborator; comfortable working with multiple key stakeholders on care delivery efforts
• Must be savvy with analytics: ability to aggregate and present data
• Must be comfortable presenting information in front of leadership and others
• Must be able to perform multiple activities, solve problems, utilize appropriate resources, make independent decisions, and work well in a team-based environment adhering to deadlines.
• Strong organizational skills a must