Continuum of Care Coordinator

Community Health Systems - Huntsville, AL

Job Title: Continuum of Care Coordinator

Position: Care Coordinator overseeing transitions in care for assigned markets

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Location

Address:

City: Huntsville

State: AL

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Job Responsibilities

Oversee the continuum of care for assigned markets within MSSP ACOs.
Manage patient transitions between hospitals, clinics, and post-acute care providers.
Conduct group and individual meetings with hospital leadership and post-acute administrators.
Promote timely access to appropriate levels of quality care to reduce readmissions and avoidable services.
Build strategic relationships in the community to enhance patient health and well-being.
Monitor data and present to hospital leadership to identify trends in resource utilization.
Develop, maintain, and coordinate the Post-Acute Care Collaborative.
Track discharge patterns for Medicare patients and collaborate with hospital and post-acute care teams.
Utilize metrics to support improvements in care quality and recommend actionable steps to hospital leadership.
Collect and communicate information to support the development and evaluation of strategic plans for ACO performance improvement.
Maintain knowledge of ACOs and value-based care programs impacting Medicare patients.
Prepare and share ACO scorecard data with primary care provider groups;
Perform other duties as assigned.
Comply with all policies and standards.

Required Skills

Core Skills

Strong knowledge of pre-acute and post-acute care resources
Care transitions management
Healthcare utilization management
Data aggregation and analysis
Interpersonal and communication skills
Organizational and problem-solving skills
Attention to detail
Ability to interpret and apply CMS benchmarks

Preferred Skills

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

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.

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