Community Health Systems Continuum of Care Coordinator (RN or Social Worker) in Cedar Park, Texas


Hospital Overview

Located minutes fromdowntown Austin, Cedar Park Regional Medical Center is a level IV DesignatedTrauma Center with more than 600 healthcare professionals working together toprovide complete inpatient, outpatient, surgical and emergency care for CedarPark and the greater Austin region.

Our culture nurtures each employee bydeveloping a sense of purpose, providing worthwhile work and giving each of usthe opportunity to make a difference in the patients we care for. Our goal isto create a great place for associates to work, physicians to practicemedicine, and patients to receive the highest level of care in the community wecall home.

Position Overview

The Continuum of CareCoordinator (CCC) is responsible for improving patient s level of wellness,reducing unnecessary readmissions and ensuring appropriate utilization of in-networkhealthcare resources. This is achievedby monitoring the ACO Care Continuum for patients discharged from CHSHospitals; which includes discussing utilization patterns of Participating andNon-participating resources, including physicians, hospitals and post-acutecare providers. The CCC will collaboratewith Hospital Leadership and Case Managers to review trends in resourceutilization. The CCC will seek toprovide assistance to patients who express concerns or additional care needs. The CCC will also seek to understandreadmission drivers and opportunities to reduce 30-day readmission penalties.


  • Works in a medical settingwith physician practices, hospital teams, PAC providers and the ACO to managethe full continuum of care in the provider network

  • Establish and maintaina Post-Acute Preferred Provider network in conjunction with CHS/ACO regulationsand bylaws

  • Evaluate the Post-AcuteReferral process and identify opportunities for improvement in a knowledgeable,skillful and consistent manner

  • Effectively utilizes carecoordination and tracking software to understand and influence readmission factorsand utilization patterns

  • Provides education to physiciansand other referral sources regarding post-acute services and in networkutilization

  • Review patient careconcerns and identify resolution of issues to meet patient care needs

  • Review ReadmissionsRates and Readmission Retention rates of Post-Acute Providers and initiatediscussions with those providers to seek improvements in performance

  • Review PAC utilizationto include ALOS, RUG levels, ED visits, and multiple PAC transfers

  • Provide monthlyutilization reports to PAC providers and ACO leadership

  • Documents interactions withpatient, family, hospital staff, and providers in accordance with thefacility-specific documentation policies

  • Regularly communicates progressin the development of the post-acute referral network

  • Establishesrelationships with community resources to mitigate patients socioeconomicissues that lead to an increase in readmission and healthcare utilization

  • Supports the goal of continuousQuality Improvement by making pertinent suggestions to improve efficiency and/orto contain costs, improve In-Network utilization/Readmission and to improve customerservice and customer satisfaction


  • Bachelor s Degree in Nursingor Social Work preferred

  • Current RegisteredNurse or Social Worker license in the state of Texas

  • Minimum of two (2) years ofstrong clinical/healthcare experience required

  • Current working knowledgeof discharge planning, utilization management, case management and disease management

  • Understanding of pre-acuteand post-acute venues of care and post-acute community resources, physician officeroutines, and transitional procedures for pre-and post-acute care

  • Supervisory and projectleadership experience a plus

  • Knowledge of Medicare andACO practice management preferred

  • Prior experience as aCare Navigator for high-risk patient populations preferred

  • Demonstrated ability to communicateeffectively in person and via telephone with patients, families/caregivers,physicians, physician office staff, and Post-Acute providers using appropriatedialogue and customer service competencies

  • Ability to aggregate andevaluate patient level data focusing on medical, psychosocial, and the educationneeds utilizing established post- acute criteria

  • Ability to perform multipleactivities, meet deadlines, solve problems, utilize resources, make independentdecisions, and work well in a team-based environment

  • Hands-on individual withgreat attention to detail, high personal accountability, and strong drive to develophim/herself while learning business model

  • Strong organizational skills

  • Proficient in MicrosoftOffice products such as Word Excel, PowerPoint, Outlook

What we offer

  • Competitive Pay

  • Medical/Dental/Vision/LifeInsurance

  • Matching 401(k)

  • Generous Paid Time Off(PTO)

  • Extended Illness Bank (EIB)

  • Tuition Reimbursement

  • RN Loan Repayment Program

  • Clinical Ladder Program

  • Employee Referral BonusProgram

  • Opportunities forcareer advancement

  • Rewards and recognitionprograms

  • Additional perks and discounts

Job: Case Management / Utilization Review

Organization: Cedar Park Regional Medical Center

Location: TX-Cedar Park

Requisition ID: 1770620