RN Clinical Care Coordinator - Denver Health (Must Live in Colorado. Weekly On-Site Requirement)

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We are recruiting for a mission-driven RN Clinical Care Coordinator - Denver Health (Must Live in Colorado. Weekly On-Site Requirement) to join our team! We're with you for life's journey. At Denver Health, purpose isn't just something we believe in-it's something we live every day, for life's journey. Our Values Respect | Belonging | Accountability | Transparency Department Managed Care Administration * Must Live in Colorado *This is a hybrid role located in Denver, Colorado with a requirement of being in the office 2 days per week. 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 required 1-3 years of experience in care coordination or case management required 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

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