RN Transition of Care Coordinator, Denver Health Medical Plan (*Must Live In Colorado*)

We are recruiting for a motivated RN Transition of Care Coordinator, Denver Health Medical Plan (*Must Live In Colorado*) to join our team!

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Department

Must Live In Colorado

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:

• Bachelor's Degree Nursing required

Work Experience:

• Two years of clinical experience in a hospital, acute care, home health/hospice, direct care or case management required
• Two 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 complex information from others.
• Knowledge of health plan case management, care coordination, or member navigation.
• Medicaid and Medicare Managed Care knowledge.
• Skills working with the needs of vulnerable populations who have chronic or complex bio-psychosocial needs.
• Knowledge and understanding of case management/coordination of care principles, programs, and processes in either a hospital or outpatient healthcare environment.
• Ability to collaboratively support team members and/or staff to achieve pre-determined goals. Effectively collaborate with and respond to varied personalities in differing emotional conditions, and maintain professional composure at all times. Strong customer service orientation and aptitude required.

Must Live In Colorado

Shift

Work Type

Salary

Benefits

• Outstanding benefits including up to 27 paid days off per year, immediate retirement plan employer contribution up to 9.5%, and generous medical plans

• Free RTD EcoPass (public transportation)

• On-site employee fitness center and wellness classes

• Childcare discount programs & exclusive perks on large brands, travel, and more

• Tuition reimbursement & assistance

• Education & development opportunities including career pathways and coaching

• Professional clinical advancement program & shared governance

• Public Service Loan Forgiveness (PSLF) eligible employer+ free student loan coaching and assistance navigating the PSLF program 

• National Health Service Corps (NHCS) and Colorado Health Service Corps (CHSC) eligible employer

Our Values

• Respect

• Belonging

• Accountability

• Transparency

All job applicants for safety-sensitive positions must pass a pre-employment drug test, once a conditional offer of employment has been made.

Denver Health is an integrated, high-quality academic health care system considered a model for the nation that includes a Level I Trauma Center, a 555-bed acute care medical center, Denver’s 911 emergency medical response system, 10 family health centers, 19 school-based health centers, Rocky Mountain Poison & Drug Safety, a Public Health Institute, an HMO and The Denver Health Foundation.

As Colorado’s primary, and essential, safety-net institution, Denver Health is a mission-driven organization that has provided billions in uncompensated care for the uninsured. Denver Health is viewed as an Anchor Institution for the community, focusing on hiring and purchasing locally as applicable, serving as a pillar for community needs, and caring for more than 185,000 individuals and 67,000 children a year.

Located near downtown Denver, Denver Health is just minutes away from many of the cultural and recreational activities Denver has to offer.

Denver Health is an equal opportunity employer (EOE). We value the unique ideas, talents and contributions reflective of the needs of our community.

Applicants will be considered until the position is filled.