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Regional Healthcare Coordination Specialist

2 months ago

Grand Junction, Colorado, United States Western Healthcare Alliance Full time

Position Overview

The Regional Care Coordinator plays a pivotal role in the enhancement and sustainability of the care coordination initiative. This includes the recruitment and ongoing support of patients engaged in care management services, ensuring the fulfillment of annual wellness visits, and facilitating discussions on advance care planning with patients. The coordinator will engage in outreach, disease management, health promotion, education, and motivational support for patients, referral sources, and the broader community. The ultimate goal is to elevate the quality of life for patients through improved health outcomes, seamless transitions of care, and encouragement of healthy lifestyle choices to mitigate the long-term impacts of chronic illnesses.

Key Responsibilities

1. Collaborate effectively with clinic personnel to deliver education and recruitment strategies.
2. Demonstrate proficiency in the Seven Domains of Care Coordination within a primary care framework:

  • Population Health Management
  • Comprehensive Assessment and Care Planning
  • Interpersonal Communication
  • Education and Coaching
  • Health Insurance and Benefits Knowledge
  • Community Resource Awareness
  • Research and Evaluation Skills

3. Conduct outreach and provide disease management and educational services to patients managing various chronic health conditions.
4. Assess and identify participants' readiness and willingness to engage in change.
5. Determine and connect with relevant community and healthcare resources to facilitate solutions and provide educational tools for self-management.
6. Collaborate with patients to establish interventions and set goals for behavioral modification within the nursing scope of practice.
7. Conduct health and wellness coaching sessions to assist participants in achieving lasting health improvements.
8. Monitor and document patient progress towards optimal wellness.
9. Promote wellness and educate patients on preventative care measures.
10. Act as a liaison among referral sources, facilities, and external entities to address and resolve continuum of care challenges.
11. Communicate with service delivery partners, providers, and other health professionals to ensure effective care coordination that optimizes healthcare resource utilization.
12. Proactively follow up with patients post-discharge from hospitals, rehabilitation facilities, and emergency rooms to facilitate their entry into care management services and ensure they have upcoming appointments with their providers.

Qualifications

To be successful in this role, candidates must possess:
- An unencumbered Registered Nurse license in the State of Colorado.
- 2-3 years of clinical experience in primary care, particularly with the geriatric population.
- Experience in patient education and goal-setting is preferred.
- A background in autonomous roles is advantageous.
- Proficiency in both English and Spanish is preferred, along with the ability to interpret various scientific and technical documents.

Competencies

Candidates should demonstrate:

  • Ability to work collaboratively with diverse individuals across various levels of the organization.
  • General knowledge of business and healthcare issues.
  • Experience with data analytics and electronic medical record systems.
  • Understanding of value-based contracting and healthcare policy.
  • Creative thinking and office management skills.
  • Capability to manage multiple projects under tight deadlines.
  • Strong verbal and written communication skills, including group presentations.
  • A valid driver's license and willingness to travel, including potential overnight stays.