Hybrid Nurse: Care Continuum Coordinator

WVU Medicine; Center (AL); Hybrid; USD 70,000 - 90,000; Full time

Job summary

SYSTEM West Virginia University Health System is seeking a Disease Management Coordinator to collaborate with patients and providers to ensure high-quality, cost-efficient care. The role involves risk stratification, discharge planning, and coordinating transitions across care settings.

Ideal candidates hold a Nursing degree with current licensure and prior care coordination experience. The position supports a hybrid work arrangement with time spent in clinic and from home.

Qualifications

• RN license either state or multi-state via eNLC.
• Background check and, if applicable, federal background check.
• Obtain Basic Life Support certification within 30 days of hire.

Responsibilities

• Ambulatory Utilization Management, Financial Management and Quality Screening for assigned patients.
• Identifies the targeted population and risk stratifies all patients to prioritize needs and direct interventions.
• 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.
• Works in collaboration with physicians/providers, patients, and their families to ensure safe and efficient transitions of care.
• Collaborates with available social services for appropriate resource and financial management including referrals and patient benefit coordination.
• Coordinates/facilitates patient progression throughout the continuum, Transitional Planning, Advocacy and Education.
• Clinical performance improvement, outcome management and quality activities.
• Uses data to drive decisions and plan/implement performance improvement strategies for assigned patients.
• Implements clinical interventions based on risk stratification and evidence-based guidelines while providing follow-up monitoring.
• Coordinates laboratory and diagnostic testing and monitors results for quality and efficiency.
• Participates in development, implementation and revision of clinical pathways and tools.
• Educates the multidisciplinary team about clinical pathways and managed care principles.
• Works with leadership to design a centralized care model that optimizes value and drives process improvement.
• Monitors clinical and financial indicators to achieve continuous improvement.

Skills

Care coordination

Nursing

Patient education

Interdisciplinary collaboration

Education

Bachelor’s Degree in Nursing

Associate’s Degree in Nursing

Job description

SYSTEM West Virginia University Health System is seeking a Disease Management Coordinator to collaborate with patients and providers to ensure high-quality, cost-efficient care. The role involves risk stratification, discharge planning, and coordinating transitions across care settings.

Ideal candidates hold a Nursing degree with current licensure and prior care coordination experience. The position supports a hybrid work arrangement with time spent in clinic and from home.