Disease Mgmt Coord- hybrid home and clinic
Core
Collaborates with patients and primary care providers to ensure quality, efficient, and cost-effective healthcare services by coordinating, monitoring, and evaluating options to optimize patient health status.
Role type
Senior Registered Nurse (Disease Management Coordinator)
Builds
Individualized plans of care and safe transitions between inpatient and outpatient levels
Domain
Healthcare / Population Health Management
Required skills
Risk stratification, Care coordination, Utilization management, Financial management, Clinical performance improvement, Data-driven decision making, Clinical interventions, Resource coordination
Preferred skills
Prior care coordination experience, Bachelor's Degree in Nursing
Technologies
Electronic Health Records (implied via data usage), Clinical pathways tools
Responsibilities
Identify targeted population and risk stratify patients to prioritize needs; Communicate and collaborate with inpatient/outpatient case management for discharge plans; Work with physicians and patients to ensure safe transitions of care; Design individualized plans of care; Collaborate with social services for resource and financial management; Coordinate laboratory and diagnostic testing; Evaluate metrics to monitor quality and efficiency; Implement clinical interventions based on risk stratification; Participate in development of clinical pathways; Educate multidisciplinary team on managed care principles; Monitor clinical and financial indicators for continuous improvement.
Seniority
Senior, hands-on IC