Disease Mgmt Coord
Core
Collaborates with patients and primary care providers to ensure quality, efficient, and cost-effective healthcare services; coordinates, monitors, and evaluates options to optimize patient health status.
Role type
Senior Registered Nurse (Disease Management & Care Coordination)
Builds
Individualized plans of care, discharge plans, and safe transitions to the next level of care
Domain
Healthcare / Disease Management / Utilization Management
Required skills
Risk stratification, Care coordination, Utilization management, Financial management, Clinical pathway development, Data-driven decision making, Clinical interventions, Resource coordination, Performance improvement, Multidisciplinary collaboration
Preferred skills
Prior care coordination experience, Bachelor's Degree in Nursing
Technologies
Electronic Health Records (implied via data usage), Clinical pathways, Diagnostic testing systems
Responsibilities
Identify targeted population and risk stratify patients to prioritize needs; Communicate and collaborate with inpatient/outpatient case management for discharge planning; Design individualized plans of care; Coordinate social services for financial assistance and entitlement programs; Monitor clinical and financial indicators for continuous improvement; Implement clinical interventions based on risk stratification and evidence-based guidelines; Evaluate laboratory results and utilization patterns; Participate in development of clinical pathways; Educate multidisciplinary team on managed care principles.
Seniority
Senior, hands-on IC