Position Summary
We are seeking a dedicated Regional Care Coordinator to enhance and maintain our care coordination program. In this role, you will be instrumental in recruiting and supporting patients enrolled in our care management services, ensuring the completion of annual wellness visits, following up on preventive care plans, and discussing advance care planning with patients. Your outreach efforts will encompass disease management, care coordination, health promotion, education, training, and motivational support for patients, referral sources, and the broader community. Your work will focus on improving the quality of life for patients by promoting positive health outcomes, facilitating smooth transitions of care, and encouraging healthy lifestyle choices to mitigate the long-term effects of chronic illness.
You will represent our clinics across multiple stakeholders and report directly to the Director of Clinical Improvement.
Key Responsibilities
- Collaborate with clinic staff to develop effective education and recruitment strategies.
- Demonstrate proficiency in the Seven Domains of Care Coordination within a primary care setting, including:
- Population Health Management
- Comprehensive Assessment and Care Planning
- Interpersonal Communication
- Education and Coaching
- Health Insurance and Benefit Knowledge
- Community Resource Knowledge
- Research and Evaluation Skills
- Conduct outreach and provide disease management, education, and other clinically-based activities for patients managing chronic health conditions, as well as to referral sources and the community.
- Assess and identify each participant’s readiness, willingness, and ability to make changes for better health.
- Recognize patient coaching, support, and educational needs with a focus on enhancing their quality of life.
- Connect patients with relevant community and healthcare resources and provide educational tools for self-management.
- Collaborate with patients to develop personalized interventions and set achievable goals for behavioral change.
- Lead health and wellness coaching sessions to support participants in achieving lasting health improvements.
- Monitor and document patient progress toward their wellness goals.
- Promote wellness and educate patients on preventive care measures.
- Serve as a liaison between referral sources, facilities, and other entities to address and resolve care continuity issues.
- Communicate effectively with service delivery partners, providers, and other health professionals to coordinate care and ensure efficient use of healthcare resources.
- Skillfully coordinate and monitor care to promote quality, effective outcomes while keeping costs in check.
- Proactively follow up with patients discharged from hospitals, rehabilitation facilities, and emergency rooms to facilitate their enrollment in care management services, ensuring they have appointments with their providers and addressing any unmet needs.
- Analyze clinical data from the electronic health record (EHR) and registry systems to identify patients with gaps in care and use risk stratification metrics for recruitment purposes.
- Assist clinics with billing inquiries related to services provided by the Regional Care Coordinator.
- Stay informed about industry trends, best practice operational models, and evolving patient and provider needs.
Location Requirement
Candidates must reside within the Western Slope region of Colorado and be within a day-trip driving distance of many member practices and hospitals for in-person visits.
Competencies
- Ability to collaborate effectively with diverse individuals at all levels of the organization and with external customers.
- General knowledge of business, healthcare, and healthcare coverage issues.
- Experience with data analytics and electronic medical record systems.
- Knowledge of value-based contracting, networking, and healthcare policy.
- Creative problem-solving skills and office management oversight capabilities.
- Ability to manage multiple projects simultaneously while meeting tight deadlines.
- Strong verbal and written communication skills, including group presentations and one-on-one interactions.
- Valid driver's license and ability to travel, including occasional overnight stays.
Qualifications
- Unencumbered Registered Nurse license in the State of Colorado.
- 2-3 years of primary care clinical experience, particularly with the geriatric population, is preferred.
- Experience in patient education and goal setting is a plus.
- Experience working in an autonomous position is preferred.
Language Skills
- Proficiency in English is required; proficiency in Spanish is preferred.
- Ability to read, analyze, and interpret scientific and technical journals, financial reports, and legal documents.
- Skill in responding to common inquiries or complaints from customers, regulatory agencies, or community members.
- Ability to write policies and procedures that align with established formats and styles.
- Competence in effectively presenting information to management, public groups, and boards.
Mathematical Skills
- Ability to perform basic arithmetic operations and understand rates, ratios, and percentages.
- Knowledge of metric, apothecary, and household measurements, with the ability to convert between measurement systems.
Reasoning Ability
- Ability to solve practical problems and handle a variety of concrete variables in situations with limited standardization.
- Ability to interpret diverse instructions in written, oral, diagram, or schedule form.
- Flexibility to adapt care based on the developmental and functional age of patients, as well as their cultural backgrounds.
Age-Specific Competency
- Ability to provide care that aligns with the developmental level and chronological age of patients, from neonatal to geriatric, understanding how these factors influence their care needs.
Other Skills And Abilities
- Strong advocacy for patients and the ability to engage effectively with patients, families, visitors, and colleagues.
- Ability to manage conflict tactfully and assertively during group problem-solving activities.
- A professional, open-minded approach to identifying and resolving challenges.
- Capability to develop creative solutions outside the healthcare setting and foster relationships with community resources.
- Effective time management skills in flexible work environments and the ability to work independently while meeting demanding deadlines.
Supervisory Responsibilities
This position does not have supervisory responsibilities.
Work Environment
The characteristics of the work environment include moderate noise levels, potential exposure to various weather conditions, and possible exposure to blood, body fluids, mechanical parts, electrical hazards, burns, radiant energy, and toxic chemicals. The role involves a flexible work environment, combining duties in primary care and specialty clinics, with some interactions in hospital settings.
Remote Work Environment
Employees must maintain patient confidentiality at all times and ensure that remote work locations, such as home offices or travel sites, meet privacy standards. Necessary equipment for remote work, including computers and mobile devices, will be provided.
Employment Type: Full-Time