Disease Mgmt Coord

WVU Medicine; West Virginia; Hybrid; USD 65,000 - 90,000; Full time

Job summary

West Virginia University Health System is seeking a Disease Management Coordinator to collaborate with patients and providers to ensure high-quality, cost-effective care. The role includes risk stratification, care transitions, and a centralized care model to optimize patient outcomes.

The position is hybrid with a primary clinic location in Morgantown and remote work from home, requiring strong communication and care coordination skills to drive improvement across the continuum.

Qualifications

• Associate's Degree in Nursing with 7 years of clinical experience or Bachelor’s Degree in Nursing with 5 years of clinical experience.
• Current RN license in the state where services are provided or multi-state license via eNLC.
• State and Federal background checks as required for regulated areas.
• BLS certification within 30 days of hire.

Responsibilities

• Ambulatory Utilization Management, Financial Management and Quality Screening for assigned patients.
• Identify the target population and risk stratify patients to prioritize needs and interventions.
• Collaborate with inpatient and outpatient case management to implement discharge plans and coordinate transitions of care.
• Work with physicians/providers, patients, and families to ensure safe transitions of care.
• Design individualized plans of care ensuring coordinated services by the healthcare team.
• Coordinate with social services for resource and financial management and referrals.
• Facilitate patient progression through the continuum and provide advocacy and education.
• Support clinical performance improvement, outcome management and quality activities.

Skills

Interpersonal communication

Negotiation

Cultural competency

Independent judgment

Education

Associate’s Degree in Nursing

Bachelor’s Degree in Nursing

RN license

BLS certification

Job description

The Disease Management Coordinator collaborates with patients and primary care providers to ensure patients receive quality, efficient, and cost-effective healthcare services. Coordinates, monitors, and evaluates all options and services to optimize a patient’s health status.

MINIMUM QUALIFICATIONS

EDUCATION, CERTIFICATION, AND/OR LICENSURE:

1. Associate’s Degree in Nursing AND Seven(7)yearsclinical experience in a healthcare setting OR Bachelor’s Degree in Nursing AND Five (5) years clinical experience in a healthcare setting.

2. Current Registered Nurse license issued by the state in which services will be provided or current multi-state Registered Nurse license through the enhanced Nurse Licensure Compact (eNLC).

3. State criminal background check and Federal (if applicable), as required for regulated areas.

4. Obtain certification in Basic Life Support within 30 days of hire date.

PREFERRED QUALIFICATIONS

EDUCATION, CERTIFICATION, AND/OR LICENSURE:

1.Bachelor’s Degree in Nursing.

EXPERIENCE:

1. Prior care coordination experience.

CORE DUTIES AND RESPONSIBILITIES:

The statements described here are intended to describe the general nature of work being performed by people assigned to this position.They are not intended to be constructed as an all-inclusive list of all responsibilities and duties.Other duties may be assigned.

1. Ambulatory Utilization Management, Financial Management and Quality Screening for assigned patients.
2. Identifies the targeted population and risk stratifies all patients to prioritize needs and direct interventions.
3. Communicates and collaborates with inpatient and outpatient case management to implement the discharge plan and coordinate a safe transition to the next level of care.
4. Works in collaboration with physicians/providers, patients, and their families to ensure safe and efficient transitions of care.
5. Works collaboratively with patients to design an individualized plan of care that ensures coordination of services by the healthcare team.
6. Collaborates with available social services for appropriate resource and financial management which may include, but is not limited to financial assistance coordination/referrals, entitlement program coordination/referrals, patient benefit coordination, assessment for appropriate usage of Health Care Resources/clinical cost efficiency.
7. Coordinates/facilitates patient progression throughout the continuum, Transitional Planning,Advocacy and Education:
8. Clinical performance improvement, outcome management and quality activities.
9. Uses data to drive decisions and plan/implement performance improvement strategies for assigned patients, including fiscal, clinical and patient satisfaction data
10. Implements clinical interventions based on risk stratification and evidence-based clinical guideline adherence and promotes best practice by initiating/adjusting therapies as directed by the practitioner and providing appropriate follow-up monitoring as needed.
11. Coordinates appropriate laboratory and diagnostic testing.
12. Continuously evaluates laboratory results, diagnostic tests, utilization patterns and other metrics to monitor quality and efficiency results for assigned population
13. Participates in development, implementation, evaluation and revision of clinical pathways and other tools.
14. Educates the multidisciplinary team and physicians about clinical pathways/protocols and managed care principles
15. Works with leadership to design, implement, and evaluate a centralized care model that optimizes value.Works with leadership to continuously evaluate process, identify problems, and propose process improvement strategies
16. Monitors clinical and financial indicators on an ongoing basis and takes action to achieve continuous improvement in both areas.

PHYSICAL REQUIREMENTS:

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.

WORKING 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.

1. Office and clinical settings

SKILLS AND ABILITIES:

1. Possesses excellent interpersonal communication and negotiation skills in interactions with patients, families, physicians, and health care team colleagues
2. Ability to work with people of all social, economic, and cultural backgrounds and be flexible, open minded, and adaptable to change
3. Capable of independent judgment and action regarding psychosocial needs of patients.

Additional Job Description:

Position is Hybrid with primary clinic POC in Morgantown and remote work from home.

Scheduled Weekly Hours:

40

Shift:

Day (United States of America)

Exempt/Non-Exempt:

United States of America (Exempt)

Company:

SYSTEM West Virginia University Health System

Cost Center:

415 POPH Population Health Management

Address:

Morgantown WV

Core

West Virginia

Equal Opportunity Employer

West Virginia University Health System and its subsidiaries (collectively “WVUHS”) is an equal opportunity employer and complies with all applicable federal, state, and local fair employment practices laws. WVUHS strictly prohibits and does not tolerate discrimination against employees, applicants, or any other covered persons because of race, color, religion, creed, national origin or ancestry, ethnicity, sex (including gender, pregnancy, sexual orientation, and gender identity), age, physical or mental disability, citizenship, past, current, or prospective service in the uniformed services, genetic information, or any other characteristic protected under applicable federal, state, or local law. All WVUHS employees, other workers, and representatives are prohibited from engaging in unlawful discrimination. This policy applies to all terms and conditions of employment, including, but not limited to, hiring, training, promotion, discipline, compensation, benefits, and termination of employment.