Job Description
Position Overview
As a Regional Care Coordinator, you'll play a vital role in enhancing the quality of life for patients by managing and growing our care coordination program. Your efforts will include recruiting and supporting patients enrolled in care management services, ensuring the completion of annual wellness visits, and discussing preventive care and advance care planning with patients. Through outreach, care coordination, and motivational support, you'll work closely with patients, referral sources, and the community to promote healthier lifestyles and smoother care transitions across the healthcare continuum.
You'll be the face of our clinics, working with various stakeholders to achieve quality outcomes. This position reports directly to the Director of Clinical Improvement.
Key Responsibilities
Collaborate with clinic staff to educate and recruit patients into our care programs.
Demonstrate expertise in the Seven Domains of Care Coordination within primary care:
Population Health Management
Comprehensive Assessment and Care Planning
Interpersonal Communication
Education/Coaching
Health Insurance and Benefit Knowledge
Community Resource Knowledge
Research and Evaluation Skills
Provide outreach, disease management, and education to patients managing chronic health conditions.
Assess patients' readiness for change and provide coaching and support tailored to their quality of life goals.
Connect patients with relevant community or healthcare resources and offer tools for self-management.
Develop and set goals with patients for behavioral changes within the scope of nursing practice.
Conduct health and wellness coaching sessions to help patients achieve lasting changes.
Monitor and document patients' progress toward optimal wellness.
Promote wellness and educate patients on preventive care measures.
Act as a liaison to resolve care coordination issues between referral sources, facilities, and other entities.
Ensure efficient use of healthcare resources through effective communication with service providers and other healthcare professionals.
Follow up with patients after hospital, rehab, or emergency room discharges to ensure they receive necessary care and support.
Analyze clinical data from EHR/Registry systems to identify patients with care gaps and recruit them into care coordination.
Assist clinics with billing inquiries related to care coordination services.
Stay current on industry trends, best practices, and changing patient and provider needs.
Location
The employee should reside within the Western Slope region of Colorado, within day-trip driving distance of our member practices and hospitals to allow for in-person visits.
Skills and Competencies
To excel in this role, you should be able to:
Collaborate effectively with diverse individuals at all levels.
Have a solid understanding of business, healthcare, and healthcare coverage issues.
Bring experience in data analytics and electronic medical record systems.
Understand value-based contracting, networking, and healthcare policy.
Think creatively and manage office operations efficiently.
Handle multiple projects with tight deadlines, working independently and as part of a team.
Communicate clearly, both verbally and in writing, including group presentations and one-on-one interactions.
Hold a valid driver's license and be able to travel, including occasional overnight stays.
Qualifications
Current Registered Nurse license in the State of Colorado.
2-3 years of clinical experience in primary care, particularly with geriatric patients, is preferred.
Experience in patient education and goal setting is a plus.
Previous experience working independently is highly desirable.
Bilingual in English and Spanish is preferred.
Work Environment
You'll enjoy a flexible work environment, splitting your time between primary care and specialty clinics, with some interactions in hospital settings.
While most of your work will be indoors, occasional exposure to outdoor conditions is possible.
The role may involve exposure to various clinical hazards, including blood and body fluids, moving machinery, and potentially hazardous chemicals.
Remote Work
Maintain patient confidentiality at all times, especially when working remotely.
You'll be equipped with the necessary technology to perform your duties from home or while traveling.
Employment Type: Full-Time
Salary: $ 32.00 43.00 Per Hour
Job Tags
Hourly pay, Full time, Outdoor, Flexible hours, Night shift,