Disease Management Coordinator - Population Health

Welcome! We’re excited you’re considering an opportunity with us! To apply to this position and be considered, click the Apply button located above this message and complete the application in full. Below, you’ll find other important information about this position. The Disease Management Coordinator collaborates with patients and primary care providers to ensure patients receive quality, efficient, and cost-effective healthcare services. Coordinates, monitors, and evaluates all options and services to optimize a patient’s health status. MINIMUM QUALIFICATIONS : EDUCATION, CERTIFICATION, AND/OR LICENSURE: 1. Associate’s Degree in Nursing AND Seven (7)years clinical experience in a healthcare setting OR Bachelor’s Degree in Nursing AND Five (5) years clinical experience in a healthcare setting. 2. Current Registered Nurse license issued by the state in which services will be provided or current multi-state Registered Nurse license through the enhanced Nurse Licensure Compact ( eNLC ). 3. State criminal background check and Federal (if applicable), as required for regulated areas. 4. Obtain certification in Basic Life Support within 30 days of hire date. PREFERRED QUALIFICATIONS : EDUCATION, CERTIFICATION, AND/OR LICENSURE: 1. Bachelor’s Degree in Nursing. EXPERIENCE: 1. Prior care coordination experience. CORE DUTIES AND RESPONSIBILITIES: The statements described here are intended to describe the general nature of work being performed by people assigned to this position. They are not intended to be constructed as an all-inclusive list of all responsibilities and duties. Other duties may be assigned. 1. Ambulatory Utilization Management, Financial Management and Quality Screening for assigned patients. 2. Identifies the targeted population and risk stratifies all patients to prioritize needs and direct interventions. 3. Communicates and collaborates with inpatient and outpatient case management to implement the discharge plan and coordinate a safe transition to the next level of care. 4. Works in collaboration with physicians/providers, patients, and their families to ensure safe and efficient transitions of care. 5. Works collaboratively with patients to design an individualized plan of care that ensures coordination of services by the healthcare team. 6. Collaborates with available social services for appropriate resource and financial management which may include, but is not limited to financial assistance coordination/referrals, entitlement program coordination/referrals, patient benefit coordination, assessment for appropriate usage of Health Care Resources/clinical cost efficiency. 7. Coordinates/facilitates patient progression throughout the continuum, Transitional Planning, Advocacy and Education: 8. Clinical performance improvement, outcome management and quality activities. 9. Uses data to drive decisions and plan/implement performance improvement strategies for assigned patients, including fiscal, clinical and patient satisfaction data 10. Implements clinical interventions based on risk stratification and evidence-based clinical guideline adherence and promotes best practice by initiating/adjusting therapies as directed by the practitioner and providing appropriate follow-up monitoring as needed. 11. Coordinates appropriate laboratory and diagnostic testing. 12. Continuously evaluates laboratory results, diagnostic tests, utilization patterns and other metrics to monitor quality and efficiency results for assigned population 13. Participates in development, implementation, evaluation and revision of clinical pathways and other tools. 14. Educates the multidisciplinary team and physicians about clinical pathways/protocols and managed care principles 15. Works with leadership to design, implement, and evaluate a centralized care model that optimizes value. Works with leadership to continuously evaluate process, identify problems, and propose process improvement strategies 16. Monitors clinical and financial indicators on an ongoing basis and takes action to achieve continuous improvement in both areas. PHYSICAL REQUIREMENTS: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. WORKING ENVIRONMENT: The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. 1. Office and clinical settings SKILLS AND ABILITIES: 1. Possesses excellent interpersonal communication and negotiation skills in interactions with patients, families, physicians, and health care team colleagues 2. Ability to work with people of all social, economic, and cultural backgrounds and be flexible, open minded, and adaptable to change 3. Capable of independent judgment and action regarding psychosocial needs of patients. Additional Job Description: Position will focus on D-SNP program and will be remote position with possible occasional travel. Scheduled Weekly Hours: 40 Shift: Day (United States of America) Exempt/Non-Exempt: United States of America (Exempt) Company: SYSTEM West Virginia University Health System Cost Center: 415 SYSTEM Population Health Management