Disease Mgmt Coord

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.

This is a hybrid position based at Family Medicine UTC in Morgantown, WV, involving both remote work and in-clinic duties.

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.
• Designs an individualized plan of care with patients to ensure coordination of services by the healthcare team.
• Collaborates with social services for resource and financial management, including financial assistance coordination, entitlement program referrals, patient benefit coordination, and assessment for appropriate usage of healthcare resources.
• Coordinates and facilitates patient progression throughout the continuum, including transitional planning, advocacy, and education.
• Uses data to drive decisions and 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.
• Coordinates appropriate laboratory and diagnostic testing and continuously evaluates results and utilization patterns.
• Participates in the 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.
• Monitors clinical and financial indicators and takes action to achieve continuous improvement.

Requirements

• Associate’s Degree in Nursing and seven (7) years of clinical experience in a healthcare setting or Bachelor’s Degree in Nursing and five (5) years of clinical experience in a healthcare setting.
• Current Registered Nurse license issued by the state in which services will be provided or current multi-state Registered Nurse license through the enhanced Nurse Licensure Compact (eNLC).
• State criminal background check and Federal (if applicable), as required for regulated areas.
• Obtain certification in Basic Life Support within 30 days of hire date.

Preferred Qualifications

• Bachelor’s Degree in Nursing.
• Prior care coordination experience.

Skills

• Excellent interpersonal communication and negotiation skills in interactions with patients, families, physicians, and healthcare team colleagues.
• Ability to work with people of all social, economic, and cultural backgrounds; flexible, open-minded, and adaptable to change.
• Capable of independent judgment and action regarding the psychosocial needs of patients.

Physical Requirements

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Working Environment

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Work settings include both office and clinical environments.

Schedule

• Scheduled Weekly Hours: 40
• Shift: Day
• Exempt status: Exempt