Position Summary
In this role, you will be instrumental in enhancing and maintaining our care coordination program. Your responsibilities will include recruiting and supporting patients enrolled in care management services, ensuring they complete their annual wellness visits, and discussing advance care planning. You will engage with patients through outreach, disease management, care coordination, education, and motivational support, focusing on improving their quality of life by promoting healthy lifestyle choices and ensuring seamless transitions of care across the healthcare continuum.
You will work collaboratively with various stakeholders to support quality outcomes and facilitate connections with community resources. Reporting to the Director of Clinical Improvement, you will advocate for patient-centered care.
Key Responsibilities
- Collaborate with clinic staff to implement effective education and recruitment strategies.
- Demonstrate competence in the Seven Domains of Care Coordination, including:
- Population Health Management
- Comprehensive Assessment and Care Planning
- Interpersonal Communication
- Education and Coaching
- Health Insurance and Benefits Knowledge
- Community Resource Knowledge
- Research and Evaluation Skills
- Provide outreach and disease management support to patients with chronic health conditions, as well as to referral sources and the community.
- Assess participants’ readiness and willingness to change, focusing on their quality of life.
- Identify coaching, support, and educational needs, connecting patients with relevant community resources and educational tools.
- Collaborate with patients to develop interventions and set goals for behavioral modification within the nursing scope of practice.
- Conduct health and wellness coaching sessions, empowering participants to make lasting changes to their health.
- Monitor and document patients’ progress towards their wellness goals.
- Promote wellness and educate patients on preventative care measures.
- Serve as a liaison between referral sources, facilities, and external partners to address continuity of care issues.
- Communicate effectively with service delivery partners, providers, and other health professionals to facilitate care coordination.
- Proactively follow up with patients discharged from hospitals, rehabilitation facilities, and emergency rooms, ensuring they have appointments with their providers and addressing any unmet needs.
- Analyze clinical data from EHR/Registry systems to identify patients with gaps in care and implement targeted recruitment strategies for care coordination.
- Assist clinics with billing inquiries related to services provided by the Regional Care Coordinator.
- Stay informed on industry trends, best practices, and the evolving needs of patients and providers.
Residence Location
Candidates must reside within the Western Slope region of Colorado and be within day-trip driving distance of member practices and hospitals for in-person visits.
Competencies
- Ability to work collaboratively with diverse individuals at all levels, including external customers.
- General knowledge of business, healthcare, and healthcare coverage issues.
- Experience with data analytics and electronic medical record systems.
- Familiarity with value-based contracting and healthcare policy.
- Creative thinking and effective office management skills.
- Strong project management abilities with the capability to handle multiple projects on tight schedules.
- Excellent verbal and written communication skills, including group presentations and one-on-one interactions.
- A valid driver’s license and willingness to travel, including occasional overnight stays.
Qualifications
- Unencumbered Registered Nurse license in the State of Colorado.
- 2-3 years of primary care clinical experience, preferably with the geriatric population.
- Experience in patient education and goal setting is preferred.
- Previous experience in an autonomous position is beneficial.
Language Skills
- Proficiency in English; Spanish is a plus.
- Ability to read, analyze, and interpret scientific and technical documents.
- Capable of responding to inquiries from customers and regulatory agencies.
- Proficient in writing policies and procedures in a prescribed format.
- Effective presentation skills for various audiences, including management and community groups.
Mathematical Skills
- Proficient in basic mathematical operations, including addition, subtraction, multiplication, and division.
- Knowledge of metric, apothecary, and household measurements, with the ability to convert between systems.
Reasoning Ability
- Ability to solve practical problems in various situations with limited standardization.
- Competence in interpreting a variety of instructions in different formats.
- Ability to adjust care based on patients’ developmental and functional ages, as well as their ethnic backgrounds.
Age-Specific Competence
- Capable of providing care appropriate to the developmental level and chronological age of patients, ranging from neonatal to geriatric populations.
Other Skills And Abilities
- Strong patient advocacy skills.
- Ability to interact positively with patients, families, visitors, and colleagues.
- Assertive and tactful in conflict resolution and group problem-solving.
- Open-minded and professional approach to identifying and resolving issues.
- Ability to develop relationships with community resources and manage time effectively in flexible environments.
Supervisory Responsibilities
This position does not have supervisory responsibilities.
Work Environment
The work environment is characterized by moderate noise levels and may include inside and outside conditions. Employees may be exposed to blood and body fluids, moving mechanical parts, electrical shock, burns, and toxic chemicals.
You will enjoy a flexible work environment, performing 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 meet privacy standards. Necessary equipment for remote work, including a computer and mobile phone, will be provided.
Employment Type: Full-Time