We are recruiting for a motivated RN Clinical Care Coordinator - Denver Health Medical Plan (* Hybrid Work Schedule *) to join our team!

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Department

Managed Care Administration

*Hybrid Work Schedule

Job Summary

Under general supervision, the Transition Care Coordinator (RNCC) is responsible for facilitating and coordinating the care delivered to an assigned group of members through multidisciplinary and member/family collaboration to ensure quality and cost effective outcomes are delivered within appropriate care coordination parameters. Coordination involves assessment, planning, support, and evaluation of member care and related outcomes. Activities to be performed are screening and assessment of medical, behavioral health and social determinants needs and gaps in care, collaboration with the Member to develop a care plan with SMART (SMART goals are: Specific, Measurable, Attainable, Relevant and Timely) goals, periodic outreach within defined timeframes to support member in achieving their goals and supporting the Members self-efficacy to navigate systems. RNCC communicates closely with the Member's care team inclusive of: the member, the member's designated health representatives, primary care provider, behavioral health providers and other care coordinators involved with the Member's care.

Essential Functions:

• Use DHMP Care Management protocols and critical thinking to assess, identify opportunities to improve Member healthcare outcomes, collaboratively set SMART goals with the Member, develop a care plan with interventions and support and enable the Member to achieve their goals and independently navigate needed services to improve overall health outcomes. (10%)
• Visit members with complex needs in community based settings, including community centers, hospitals or providers' offices. (10%)
• Provide a complete continuum of quality care through close communication with members via in-person, phone or electronic interaction. (10%)
• Support members with education relevant to their disease process, medication reviews and connections to community resources such as food, housing or financial support programs. (10%)
• The RNCC will work with members with complex needs, prioritize care management and work with a multidisciplinary team to support the needs of the Members on their caseloads. (10%)
• Document in readable, understandable language according to professional, regulatory, and agency standards. (10%)
• Document and disseminate results of care to member, caregivers, and others involved in the care or situation, as appropriate, in accordance with contractual requirements, state and federal laws, regulatory requirements, and Denver Health policy. (10%)
• RNCC will be responsible for a defined caseload of Members identified as needing Complex Care Management (CCM) or Population Health Management/Disease Management (PHM) services. (10%)
• Members meet the threshold for CCM by meeting defined threshold conditions, including multiple chronic physical health and/or behavioral health conditions, polypharmacy, high costs of care, avoidable use of high cost services and/or associated social health disparities. (10%)
• Members meet the threshold for PHM by having at least one of several defined conditions, including a chronic physical or behavioral health condition, like diabetes or depression; a person with special health care needs; high-risk pregnancy or other identified condition. (10%)

Education:

• Associate's Degree Nursing required

Work Experience:

• 1-3 years of clinical experience in a hospital, acute care, home health/hospice, direct care or case management required AND
• 1-3 years of experience in care coordination or case management required

Licenses:

• RN-Registered Nurse - DORA - Department of Regulatory Agencies required

Knowledge, Skills and Abilities:

• Must have reliable transportation to travel to community-based locations within the Denver-metro area.
• Bilingual ability English/Spanish.
• Problem solving skills; the ability to systematically analyze problems, draw relevant conclusions and devise appropriate courses of action.
• Ability to communicate verbally and in writing complex or technical information in a manner that others can understand, as well as ability to understand and interpret comp