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Job Description:

Position Summary:  Provides care coordination services to Health First Colorado members to support Colorado Community Health Alliance (CCHA) initiatives and the Primary Care Medical Provider’s efforts in providing a medical home for Health First Colorado members.  Focuses on patient self-management and increase knowledge of patient’s disease process by providing coaching, health education, home visits, follow-up and support services as well as communicate patient information and care treatment plans back to primary care medical providers.  Increase patient’s ability to access timely and appropriate health care services, community resources and referrals, and guide patients through our Transitions of Care program to optimize member health outcomes.

COMPETENCIES/Role-Specific Functions: 

COMMUNICATION

Communicates well both verbally and in writing, creates accurate and punctual reports, delivers presentations, shares information and ideas with others, has good listening skills.

• Functions as a liaison and advocate for Health First Colorado members between referring providers, specialty physicians, referral care coordinators or other relevant staff and community resources to include care conferences and member updates to their care team.

• Communicate with providers to get supporting documentation needed to complete service coordination plan.

PROBLEM SOLVING

Breaks down problems into smaller components, understands underlying issues, can simplify and process complex issues, understands the difference between critical details and unimportant facts. 

• Completes comprehensive assessments to identify needs and barriers to the member’s ability to manage their medical conditions and treatment plans and participates with the member, caregivers, the primary care medical provider and health care team in developing a comprehensive care plan to overcome identified needs barriers.

PRODUCTIVITY

Manages a fair workload, volunteers for additional work, prioritizes tasks, develops good work procedures, manages time well, handles information flow.

• Meets case workload and documentation requirements as outlined by department standards.

SELF DEVELOPMENT

Seeks out and accepts feedback, is a proactive learner, takes on tough assignments to improve skills, keeps knowledge and skills up-to-date, turns mistakes into learning opportunities.

• Fulfills requirements necessary to maintain licensure. Conferences, publications, etc. to stay current on new treatments and trends.

CUSTOMER FOCUS

Builds customer confidence, is committed to increasing customer satisfaction, sets achievable customer expectations, assumes responsibility for solving customer problems, ensures commitments to customers are met, solicits opinions and ideas from customers, responds to customers.

• Develops strong telephonic and in-person relationships with Health First Colorado members that include assessing for care coordination needs, providing health education, case coordination for Health First Colorado patients and their caregivers with complex medical and psychosocial issues, developing a joint care plan, providing member referrals to medical and non-medical resources and educating on the health care system.

• Develop and maintain a good working relationship with assigned primary care medical practices, healthcare teams, patients, families, and Hospitals.

JOB KNOWLEDGE

Understands duties and responsibilities, has necessary job knowledge, has necessary technical skills, understands company mission/values, keeps job knowledge current, is in command of critical issues.

• Identify potential program candidates by using available utilization data , hospital census data, physician referrals and referrals from other sources and provide comprehensive nurse care coordination to include identifying and overcoming medical, psych-social, community, cultural religious and financial barriers

• Works closely with health partner team to timely meet the care coordination needs of Health First Colorado members to include keeping up to date on current Health First Colorado, CCHA and community programs resources.

• Maintain confidentiality and ensure compliance with HIPAA regulations.

• Other duties as assigned.

Qualifications (Education/Experience/Knowledge/Skills/Abilities): 

• Bilingual (English/Spanish) preferred.

• RN with valid license in good standing.  (Required Licensure or Certification for this position must be maintained by the employee as defined by the company policies and procedures) 

• Three to five years case management experience or a combination of relevant experience with at least two years’ work experience in community setting, i.e. home health care, discharge planning, department of social services, etc. 

• Previous experience with Health First Colorado highly preferred.

• Knowledge of Care Transitions Coaching/Transitions of Care model (preferred).

• Skilled in Motivational Interviewing preferred.

• Excellent verbal and written communication skills and the ability to convey information clearly to both internal staff and external members/partners.

• Intermediate level of competence on computer and internet skills required for routine data collection, data entry and reporting; intermediate experience with Microsoft Outlook, Microsoft Word and Microsoft Excel Spreadsheets.

• Ability to work well in group and independent problem solving situations.

• Excellent time management skills and ability to complete tasks on time; ability to multi-task.

• A valid unrestricted Colorado drivers’ license. 

• Reliable and insured vehicle.

• Home office that is HIPAA compliant for all remote or telecommuting positions as outlined by the company policies and procedures. 

• Mobile Device for work purposes as defined by the company policies and procedures.

Physical Demands The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.  While performing the duties of this Job, the employee is regularly required to sit; use hands to finger, handle, or feel and talk or hear.  The employee is frequently required to stand; walk; reach with hands and arms and stoop, kneel, crouch, or crawl.  The employee is occasionally required to climb or balance. The employee must regularly lift and/or move up to 25 pounds.  Specific vision abilities required by this job include close vision and ability to adjust focus.

Work Environment The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. 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.

Salary Range:

RN $65,711 - $98,567