Disease Management Coordinator

This role supports patients with complex health needs by coordinating care plans, improving outcomes, and ensuring access to high-quality healthcare services. The position works closely with patients, providers, families, and multidisciplinary teams to deliver personalized care management solutions. With a focus on chronic disease support, utilization management, and health improvement initiatives, the role helps drive better clinical and financial outcomes. The ideal candidate is a compassionate and analytical healthcare professional who can balance patient advocacy with evidence-based care practices. This position offers the opportunity to make a meaningful impact by improving care coordination and supporting patients throughout their healthcare journey.

Accountabilities

• Coordinate, monitor, and evaluate healthcare services to support safe, effective, and cost-efficient patient care.
• Identify high-risk patient populations and apply risk stratification methods to prioritize interventions and care management activities.
• Collaborate with physicians, providers, patients, families, and multidisciplinary teams to develop and implement individualized care plans.
• Support transitions of care by coordinating discharge planning, follow-up services, and communication between inpatient and outpatient care teams.
• Provide patient education, advocacy, and support to encourage adherence to treatment plans and promote better health outcomes.
• Manage care coordination activities for patients with chronic conditions, with a primary focus on heart failure management.
• Monitor clinical, financial, and patient satisfaction metrics to identify opportunities for improvement.
• Use healthcare data and performance indicators to guide decision-making and implement improvement strategies.
• Apply evidence-based guidelines and clinical pathways to support appropriate interventions and follow-up care.
• Coordinate laboratory testing, diagnostic evaluations, and ongoing monitoring of patient progress.
• Partner with social services and community resources to assist patients with financial support, benefits coordination, and access to care.
• Participate in the development and improvement of clinical programs, workflows, and care management models.
• Educate healthcare teams on clinical pathways, quality initiatives, and managed care principles.

Requirements

• Associate Degree in Nursing with 7+ years of clinical healthcare experience, or Bachelor’s Degree in Nursing with 5+ years of clinical healthcare experience.
• Current Registered Nurse (RN) license in the state where services are provided, or an active multi-state RN license through the enhanced Nurse Licensure Compact (eNLC).
• Bachelor’s Degree in Nursing preferred.
• Prior experience in care coordination, disease management, utilization management, or population health preferred.
• Ability to assess patient needs, develop care strategies, and make independent clinical decisions.
• Strong interpersonal communication and negotiation skills when working with patients, families, providers, and healthcare teams.
• Ability to work effectively with individuals from diverse social, economic, and cultural backgrounds.
• Strong organizational skills with the ability to manage multiple priorities and complex patient cases.
• Knowledge of evidence-based clinical practices, healthcare resources, and quality improvement principles.
• Ability to obtain Basic Life Support (BLS) certification within 30 days of hire.
• Completion of required background screening.

Benefits

• Full-time remote work opportunity.
• Competitive compensation package.
• Comprehensive healthcare benefits and wellness programs.
• Opportunities for professional development and career growth.
• Ability to make a direct impact on patient care and population health outcomes.
• Collaborative environment with healthcare professionals across multiple disciplines.
• Supportive workplace focused on quality improvement, innovation, and patient-centered care.