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Port Charlotte

    continuum of care coordinator - Port Charlotte, FL , USA, United States - Community Health System

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    Description
    Job Description


    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:

    • Collaboration with Case Management on appropriate and timely discharges to post-acute services.
    • Serve as a liaison between ACO hospitals 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 supported markets.
    • 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.


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