Disease Mgmt Coord-Cheat Lake Hybrid

WVU Medicine•Cheat Lake, WV

3d•Hybrid

About The Position

The Disease Management Coordinator collaborates with patients and primary care providers to ensure patients receive quality, efficient, and cost-effective healthcare services. The coordinator organizes, monitors, and evaluates available options and services to optimize patients’ health status. The role includes ambulatory utilization management, financial management, and quality screening for assigned patients, as well as coordinating patient progression and transitions across the continuum of care. The position works with patients, families, providers, inpatient and outpatient case management, social services, and other members of the healthcare team.

Requirements

Associate’s Degree in Nursing and seven years of clinical experience in a healthcare setting, or Bachelor’s Degree in Nursing and five years of clinical experience in a healthcare setting.
Current Registered Nurse license issued by the state where services will be provided, or a current multistate Registered Nurse license through the enhanced Nurse Licensure Compact (eNLC).
State criminal background check and federal background check, if applicable, as required for regulated areas.
Obtain Basic Life Support certification within 30 days of hire.
Excellent interpersonal communication and negotiation skills when interacting with patients, families, physicians, and healthcare team colleagues.
Ability to work with people from varied social, economic, and cultural backgrounds and to be flexible, open-minded, and adaptable to change.
Ability to exercise independent judgment and action regarding patients’ psychosocial needs.

Nice To Haves

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

Responsibilities

Perform ambulatory utilization management, financial management, and quality screening for assigned patients.
Identify the target population and risk-stratify patients to prioritize needs and direct interventions.
Collaborate with inpatient and outpatient case management to implement discharge plans and coordinate safe transitions to the next level of care.
Work with physicians and other providers, patients, and families to support safe and efficient transitions of care.
Work with patients to develop individualized plans of care that coordinate services across the healthcare team.
Collaborate with social services on appropriate resource and financial management, including financial assistance and entitlement program referrals, patient benefit coordination, and assessment of appropriate healthcare resource use and clinical cost efficiency.
Coordinate and facilitate patient progression throughout the continuum of care, including transitional planning, advocacy, and education.
Participate in clinical performance improvement, outcome management, and quality activities.
Use fiscal, clinical, and patient satisfaction data to make decisions and plan and implement performance improvement strategies for assigned patients.
Implement clinical interventions based on risk stratification and evidence-based guideline adherence; promote best practices by initiating or adjusting therapies as directed by the practitioner and providing follow-up monitoring as needed.
Coordinate appropriate laboratory and diagnostic testing.
Evaluate laboratory results, diagnostic tests, utilization patterns, and other metrics to monitor quality and efficiency for the assigned population.
Participate in the development, implementation, evaluation, and revision of clinical pathways and other tools.
Educate the multidisciplinary team and physicians about clinical pathways, protocols, and managed care principles.
Work with leadership to design, implement, and evaluate a centralized care model that optimizes value; evaluate processes, identify problems, and propose improvement strategies.
Monitor clinical and financial indicators and take action to support continuous improvement.