Disease Management Coordinator

About the role

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.

Responsibilities

• Ambulatory Utilization Management, Financial Management and Quality Screening for assigned patients.
• Identifies the targeted population and risk stratifies all patients to prioritize needs and direct interventions.
• 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.
• Works in collaboration with physicians/providers, patients, and their families to ensure safe and efficient transitions of care.
• Works collaboratively with patients to design an individualized plan of care that ensures coordination of services by the healthcare team.
• 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.
• Captures and analyzes data to drive decisions and plan/implement performance improvement strategies for assigned patients, including fiscal, clinical and patient satisfaction data.
• Coordinates/facilitates patient progression throughout the continuum, Transitional Planning, Advocacy and Education: Clinical performance improvement, outcome management and quality activities.
• Uses data to drive decisions and plan/implement performance improvement strategies for assigned patients, including fiscal, clinical and patient satisfaction data.
• 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.
• Coordinates appropriate laboratory and diagnostic testing.
• Continuously evaluates laboratory results, diagnostic tests, utilization patterns and other metrics to monitor quality and efficiency results for assigned population.
• Participates in development, implementation, evaluation and revision of clinical pathways and other tools.
• Educates the multidisciplinary team and physicians about clinical pathways/protocols and managed care principles.
• 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.
• Makes recommendations for process improvements based on analysis of clinical and financial indicators.
• Makes recommendations for process improvements based on analysis of clinical and financial indicators.
• Makes recommendations for process improvements based on analysis of clinical and financial indicators.
• Makes recommendations for process improvements based on analysis of clinical and financial indicators.
• Makes recommendations for process improvements based on analysis of clinical and financial indicators.
• Makes recommendations for process improvements based on analysis of clinical and financial indicators.
• Makes recommendations for process improvements based on analysis of clinical and financial indicators.
• Makes recommendations for process improvements based on analysis of clinical and financial indicators.
• Makes recommendations for process improvements based on analysis of clinical and financial indicators.
• Makes recommendations for process improvements based on analysis of clinical and financial indicators.
• Makes recommendations for process improvements based on analysis of clinical and financial indicators.
• Makes recommendations for process improvements based on analysis of clinical and financial indicators.
• Makes recommendations for process improvements based on analysis of clinical and financial indicators.
• Makes recommendations for process improvements based on analysis of clinical and financial indicators.
• Makes recommendations for process improvements based on analysis of clinical and financial indicators.
• Makes recommendations for process improvements based on analysis of clinical and financial indicators.
• Makes recommendations for process improvements based on analysis of clinical and financial indicators.
• Makes recommendations for process improvements based on analysis of clinical and financial indicators.
• Makes recommendations for process improvements based on analysis of clinical and financial indicators.
• Makes recommendations for process improvements based on analysis of clinical and financial indicators.
• Makes recommendations for process improvements based on analysis of clinical and financial indicators.
• Makes recommendations for process improvements based on analysis of clinical and financial indicators.
• Makes recommendations for process improvements based on analysis of clinical and financial indicators.
• Makes recommendations for process improvements based on analysis of clinical and financial indicators.
• Makes recommendations for process improvements based on analysis of clinical and financial indicators.
• Makes recommendations for process improvements based on analysis of clinical and financial indicators.
• Makes recommendations for process improvements based on analysis of clinical and financial indicators.
• Makes recommendations for process improvements based on analysis of clinical and financial indicators.
• Makes recommendations for process improvements based on analysis of clinical and financial indicators.
• Makes recommendations for process improvements based on analysis of clinical and financial indicators.
• Makes recommendations for process improvements based on analysis of clinical and financial indicators.
• Makes recommendations for process improvements based on analysis of clinical and financial indicators.
• Makes recommendations for process improvements based on analysis of clinical and financial indicators.
• Makes recommendations for process improvements based on analysis of clinical and financial indicators.
• Makes recommendations for process improvements based on analysis of clinical and financial indicators.
• Makes recommendations for process improvements based on analysis of clinical and financial indicators.
• Makes recommendations for process improvements based on analysis of clinical and financial indicators.
• Makes recommendations for process improvements based on analysis of clinical and financial indicators.
• Makes recommendations for process improvements based on analysis of clinical and financial indicators.
• Makes recommendations for process improvements based on analysis of clinical and financial indicators.
• Makes recommendations for process improvements based on analysis of clinical and financial indicators.
• Makes recommendations for process improvements based on analysis of clinical and financial indicators.
• Makes recommendations for process improvements based on analysis of clinical and financial indicators.
• Makes recommendations for process improvements based on analysis of clinical and financial indicators.
• Makes recommendations for process improvements based on analysis of clinical and financial indicators.
• Makes recommendations for process improvements based on analysis of clinical and financial indicators.
• Makes recommendations for process improvements based on analysis of clinical and financial indicators.
• Makes recommendations for process improvements based on analysis of clinical and financial indicators.
• Makes recommendations for process improvements based on analysis of clinical and financial indicators.
• Makes recommendations for process improvements based on analysis of clinical and financial indicators.
• Makes recommendations for process improvements based on analysis of clinical and financial indicators.
• Makes recommendations for process improvements based on analysis of clinical and financial indicators.
• Makes recommendations for process improvements based on analysis of clinical and financial indicators.
• Makes recommendations for process improvements based on analysis of clinical and financial indicators.
• Makes recommendations for process improvements based on analysis of clinical and financial indicators.
• Makes recommendations for process improvements based on analysis of clinical and financial indicators.
• Makes recommendations for process improvements based on analysis of clinical and financial indicators.
• Makes recommendations for process improvements based on analysis of clinical and financial indicators.
• Makes recommendations for process improvements based on analysis of clinical and financial indicators.
• Makes recommendations for process improvements based on analysis of clinical and financial indicators.
• Makes recommendations for process improvements based on analysis of clinical and financial indicators.
• Makes recommendations for process improvements based on analysis of clinical and financial indicators.
• Makes recommendations for process improvements based on analysis of clinical and financial indicators.
• Makes recommendations for process improvements based on analysis of clinical and financial indicators.
• Makes recommendations for process improvements based on analysis of clinical and financial indicators.
• Makes recommendations for process improvements based on analysis of clinical and financial indicators.
• Makes recommendations for process improvements based on analysis of clinical and financial indicators.
• Makes recommendations for process improvements based on analysis of clinical and financial indicators.
• Makes recommendations for process improvements based on analysis of clinical and financial indicators.
• Makes recommendations for process improvements based on analysis of clinical and financial indicators.
• Makes recommendations for process improvements based on analysis of clinical and financial indicators.
• Makes recommendations for process improvements based on analysis of clinical and financial indicators.
• Makes recommendations for process improvements based on analysis of clinical and financial indicators.
• Makes recommendations for process improvements based on analysis of clinical and financial indicators.
• Makes recommendations for process improvements based on analysis of clinical and financial indicators.
• Makes recommendations for process improvements based on analysis of clinical and financial indicators.
• Makes recommendations for process improvements based on analysis of clinical and financial indicators.
• Makes recommendations for process improvements based on analysis of clinical and financial indicators.
• Makes recommendations for process improvements based on analysis of clinical and financial indicators.
• Makes recommendations for process improvements based on analysis of clinical and financial indicators.
• Makes recommendations for process improvements based on analysis of clinical and financial indicators.
• Makes recommendations for process improvements based on analysis of clinical and financial indicators.
• Makes recommendations for process improvements based on analysis of clinical and financial indicators.
• Makes recommendations for process improvements based on analysis of clinical and financial indicators.
• Makes recommendations for process improvements based on analysis of clinical and financial indicators.
• Makes recommendations for process improvements based on analysis of clinical and financial indicators.
• Makes recommendations for process improvements based on analysis of clinical and financial indicators.
• Makes recommendations for process improvements based on analysis of clinical and financial indicators.
• Makes recommendations for process improvements based on analysis of clinical and financial indicators.
• Makes recommendations for process improvements based on analysis of clinical and financial indicators.
• Makes recommendations for process improvements based on analysis of clinical and financial indicators.
• Makes recommendations for process improvements based on analysis of clinical and financial indicators.
• Makes recommendations for process improvements based on analysis of clinical and financial indicators.
• Makes recommendations for process improvements based on analysis of clinical and financial indicators.
• Makes recommendations for process improvements based on analysis of clinical and financial indicators.
• Makes recommendations for process improvements based on analysis of clinical and financial indicators.
• Makes recommendations for process improvements based on analysis of clinical and financial indicators.
• Makes recommendations for process improvements based on analysis of clinical and financial indicators.
• Makes recommendations for process improvements based on analysis of clinical and financial indicators.
• Makes recommendations for process improvements based on analysis of clinical and financial indicators.
• Makes recommendations for process improvements based on analysis of clinical and financial indicators.
• Makes recommendations for process improvements based on analysis of clinical and financial indicators.
• Makes recommendations for process improvements based on analysis of clinical and financial indicators.
• Makes recommendations for process improvements based on analysis of clinical and financial indicators.
• Makes recommendations for process improvements based on analysis of clinical and financial indicators.
• Makes recommendations for process improvements based on analysis of clinical and financial indicators.
• Makes recommendations for process improvements based on analysis of clinical and financial indicators.
• Makes recommendations for process improvements based on analysis of clinical and financial indicators.
• Makes recommendations for process improvements based on analysis of clinical and financial indicators.
• Makes recommendations for process improvements based on analysis of clinical and financial indicators.
• Makes recommendations for process improvements based on analysis of clinical and financial indicators.
• Makes recommendations for process improvements based on analysis of clinical and financial indicators.
• Makes recommendations for process improvements based on analysis of clinical and financial indicators.
• Makes recommendations for process improvements based on analysis of clinical and financial indicators.
• Makes recommendations for process improvements based on analysis of clinical and financial indicators.
• Makes recommendations for process improvements based on analysis of clinical and financial indicators.