Continuum of Care Coordinator

Community Health Systems - Huntsville, AL

Job Title: Continuum of Care Coordinator

Position: Care Coordinator

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Location

Address:

City: Huntsville

State: AL

ZIP Code:

Job Responsibilities

Oversees the continuum of care in assigned markets for MSSP ACOs.
Manages patient transitions between hospitals, clinics, and post-acute care providers.
Conducts group and individual meetings with hospital leadership and post-acute administrators.
Promotes timely access to appropriate levels of quality care.
Works to reduce readmissions, avoidable hospital services, length of stay, and home health recertification.
Builds strategic relationships in the community to enhance patient health and well-being.
Monitors data and presents to hospital leadership to identify trends in resource utilization.
Serves as a local subject-matter expert (SME) on ACO for supported markets.
Develops, maintains, and coordinates the Post-Acute Care Collaborative for assigned markets.
Tracks discharge patterns for Medicare patients.
Collaborates with hospital and post-acute care teams to support ACO benchmarks.
Utilizes data to support improvement in care quality for ACO patients.
Recommends actionable steps to hospital leadership to meet CMS benchmarks.
Collects and communicates information on successes and barriers to the Payment Innovations team.
Maintains current knowledge of ACOs and value-based care programs.
Prepares and shares ACO scorecard data with primary care provider groups.
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.

Required Skills

Core Skills

Strong knowledge of pre-acute and post-acute care resources
Care transitions and healthcare utilization management
Data aggregation and analysis
Interpersonal and communication skills
Organizational and problem-solving skills
Attention to detail

Preferred Skills

Advanced proficiency in Google Suite and Microsoft Excel
Experience as a Care Navigator for high-risk patient populations

Requirements

Experience: 2-4 years of strong clinical or healthcare experience, with a focus on hospital discharge planning, utilization management, and case management.

Education: Associate Degree in Nursing or Healthcare Management required; Bachelor's Degree in Healthcare Administration or related field preferred.

License & Certification: