Population Health/Concierge Care Coordination, RN

Position Summary:

The Population Health and Care Coordinator plays a critical role in overseeing chronic disease management, care coordination, complex case management, and programs aimed at improving quality of life and closing gaps in care for members within the manage care system. This position is responsible for coordinating, educating, and providing expertise to members across the continuum of care, from managing complex medical conditions to addressing chronic diseases. The coordinator promotes adherence to preventative care measures and facilitates healthcare interventions at the most appropriate and safe level, empowering members to self-manage their chronic conditions and take control of their health.

This role supports the practitioner-patient relationship by aligning with the established plan of care, utilizing cost-effective and evidence-based practice guidelines. The primary objectives are to address acute healthcare needs, prevent or delay the progression of severe disease stages, and enhance the overall quality of life for members. Through this approach, the Population Health and Care Coordinator works to reduce complications, morbidity, and healthcare costs, ensuring that members receive comprehensive and coordinated care.

The coordinator's responsibilities are carried out in accordance with the requirements of Medicaid contracts, Community Care Plan (CCP) Health Services policies and procedures, and Patient-Centered Medical Home (PCMH) standards, ensuring compliance with all relevant regulations and guidelines.

By facilitating collaboration among healthcare providers, social services, and community resources, the Population Health and Care Coordinator plays a pivotal role in achieving positive health outcomes and improving the overall well-being of the members served.

Essential Duties and Responsibilities:

Lead and Coordinate Multidisciplinary Team Efforts:

• Assigned to one or more physician practices, lead a multi-disciplinary team to identify clients with the highest levels of morbidity, risk, utilization, cost, and gaps in care. Implement strategies to collaborate with providers to improve patient outcomes and quality of care.

Care Coordination and Assessment:

• Analyze clinical information to identify eligible members for the Concierge Care Coordination Program.
• Conduct a thorough needs assessment for all identified enrollees, including risk stratification to determine health, psychological, educational, and social needs, and establish the level of care required.
• Review daily census for hospitalized enrollees within the panel; assess needs and coordinate discharge planning.
• Evaluate hospitalized enrollees for ongoing care coordination, disease management, or open gaps in care, and collaborate with hospitals and providers to address needs.

Develop and Monitor Individualized Care Plans:

• Collaborate with physicians and enrollees to develop individualized care plans.
• Establish Specific, Measurable, Achievable, Realistic, and Time-bound (SMART) goals that address identified needs, improve quality of life, and evaluate cost and quality outcomes.
• Regularly update care plans as changes in enrollee status occur, and at least annually; communicate with the multidisciplinary team as needed.

Member Engagement and Education:

• Conduct outreach to enrollees with chronic conditions, multiple gaps in care, or those needing preventive services.
• Provide education on disease processes, healthy lifestyle changes, and self-management of chronic conditions, consistent with clinical practice guidelines.
• Educate members on shared decision-making tools to ensure they are informed of all care options, including potential benefits and risks.
• Empower members to self-manage their conditions to enhance their quality of life.

Monitoring and Follow-Up:

• Conduct outreach and follow-up for enrollees with frequent emergency room visits to identify contributing factors and develop strategies to reduce avoidable ER and hospital admissions.
• Monitor clinical outcomes, ensure timely medical care, and promote adherence to recommended preventive care, screenings, and medication regimens.
• Assess barriers when members do not meet treatment goals, do not follow the care plan, or miss important appointments.

Collaboration and Communication:

• Facilitate coordination, communication, and collaboration with members, providers, and other stakeholders to achieve care goals and optimize positive outcomes.
• Conduct or participate in team huddles to review strategies, identify clients or providers with immediate needs, and develop action plans.
• Conduct multidisciplinary team conferences as needed for clients with significant clinical, social, or behavioral health concerns.

Compliance and Documentation:

• Maintain documentation requirements to meet compliance with quality standards and accreditation requirements related to disease management and care management programs.
• Acknowledge and protect patient rights regarding confidentiality; adhere to HIPAA guidelines and regulations at all times.
• Refer cases to the medical director for any questionable, quality, or inappropriate treatment regimens.

Additional Responsibilities:

• Assist in conducting in-home assessments with Concierge Care Coordination Health Social Worker, as needed, to evaluate home safety, appropriateness of the setting, and ensure members have all necessary supplies and medications.
• Support the practitioner-patient relationship and care plan with a focus on preventing disease exacerbation and complications.
• Complete other projects, assignments, and duties as assigned to support the goals of the care coordination program.

This job description in no way states or implies that these are the only duties performed by the employee occupying this position. Employees will be required to perform any other job-related duties assigned by their supervisor or management.

Skills and Abilities:

Self-Motivation and Independence:

• Demonstrates the ability to self-motivate and work independently, managing time and resources effectively to complete tasks with minimal supervision.

Communication:

• Exceptional oral and written communication skills, with the ability to clearly convey complex information to diverse audiences, including patients, healthcare providers, and team members.
• Strong interpersonal communication skills, with the ability to effectively collaborate and build relationships within multidisciplinary teams.

Organizational and Problem-Solving Skills:

• Highly organized with excellent problem-solving abilities, capable of managing multiple priorities and tasks in a dynamic healthcare environment.
• Skilled in professional interaction and human relations, with the ability to navigate complex patient and provider interactions.

Team Collaboration:

• Proficient in processes to build and participate in cross-functional teams, promoting a collaborative approach to care coordination and complex case management.

Project Management:

• Ability to follow through on projects or assignments to successful completion, demonstrating decisive judgment and a commitment to quality outcomes.

Motivational Interviewing and Education:

• Experience with motivational interviewing techniques and understanding of adult learning styles to engage and educate members in self-management of their conditions.

Analytical Skills:

• Strong analytical skills with the ability to read and interpret various documents, including safety rules, operating and maintenance instructions, and procedure manuals.
• Ability to write routine reports and correspondence and to present information effectively before groups of customers or employees.

Mathematical Skills:

• Competent in basic mathematical skills, including the ability to add, subtract, multiply, and divide in all units of measure. Capable of computing rates, ratios, and percentages, and interpreting bar graphs.

Practical Problem-Solving:

• Ability to solve practical problems and address a variety of concrete variables in situations where only limited standardization exists. Able to interpret various instructions furnished in written, oral, diagram, or schedule form.

Physical Demands:

The physical demands outlined below are representative of those required for an employee to successfully perform the essential functions of this role. Reasonable accommodations may be made to enable individuals with disabilities to fulfill these essential functions.

• Regular Activities: While performing the duties of this job, the employee is regularly required to sit for extended periods, use hands to handle or feel objects, tools, or controls, reach with hands and arms, and communicate verbally to effectively interact with team members and enrollees.
• Frequent Activities: The employee is frequently required to stand, walk, and sit, which may involve moving between different areas of the work environment.
• Occasional Activities: The employee may occasionally be required to stoop, kneel, crouch, or crawl to perform specific tasks or to access certain areas.

Lifting Requirements: The employee may occasionally need to lift and/or move items weighing up to 15 pounds.

Work Environment:

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of the job. The environment includes work inside/outside the office, travel to other offices, as well as domestic, travel. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. The noise level in the work environment is usually moderate.

We are an equal opportunity employer who recruits, employs, trains, compensates and promotes regardless of age, color, disability, ethnicity, family or marital status, gender identity or expression, language, national origin, physical and mental ability, political affiliation, race, religion, sexual orientation, socio-economic status, veteran status, and other characteristics that make our employees unique. We are committed to fostering, cultivating, and preserving a culture of diversity, equity and inclusion.

Work Schedule:

As a continued effort to provide a safe and productive work environment, Community Care Plan is currently following a hybrid work schedule. Staff are able to work from home 3 days a week and will report to the office 2 days a week. *****The company reserves the right to change the work schedules based on the company needs.

• Bachelors Degree in Nursing.
• Masters Degree in Nursing (Preferred)

Certificates and Licenses:

• Registered Nurse licensure in the state of Florida
• Certified Case Manager (Preferred)

Experience:

Clinical Experience:

• 3-5 years of clinical experience in managing chronic diseases, complex medical cases, or care coordination, preferably in settings such as hospitals, outpatient clinics, or community health organizations.

Experience in Managed Care/Health Plan Setting:

• 3-5 years of experience working in a managed care, health plan, or insurance environment, specifically in roles related to chronic disease management, case management, or care coordination.

Care Coordination and Case Management:

• Demonstrated experience in coordinating care for members with complex medical needs, including conducting needs assessments, developing care plans, and collaborating with multidisciplinary teams to close gaps in care and improve health outcomes.

Utilization Management:

• Experience with utilization management processes, including prior authorizations, appeals, and reviewing clinical documentation to ensure appropriate use of healthcare resources.

Regulatory Knowledge:

• Familiarity with Medicaid, Medicare, or other state and federal healthcare programs, including knowledge of relevant regulations, compliance standards, and quality benchmarks.

Technical Proficiency:

• Proficient in Microsoft Office Suite and other relevant software for documentation and data management.
• Experience with electronic health records (EHR) systems such as EPIC, JIVA, or similar platforms is preferred.