Disease Management Coordinator – Population Health

This is a fully remote position, open to applicants in Virginia, +1 more state.

📋 Description

• Collaborate with patients and primary care providers to ensure high-quality, efficient, and cost-effective healthcare services.

• Coordinate, monitor, and assess options and services to enhance patients’ health status.

• Conduct ambulatory utilization management, financial management, and quality screenings for assigned patients.

• Identify target populations and stratify patients based on risk to prioritize needs and direct interventions.

• Work with inpatient and outpatient case management to implement discharge plans and ensure safe transitions of care.

• Collaborate with physicians, providers, patients, and families during transitions of care.

• Design personalized care plans and coordinate the services of the healthcare team.

• Coordinate social services, financial assistance, entitlement programs, and patient benefits.

• Facilitate patient progression, transitional planning, advocacy, and education.

• Utilize fiscal, clinical, and patient satisfaction data to inform decisions and implement performance improvement strategies.

• Implement clinical interventions based on risk stratification and evidence-based guidelines.

• Oversee laboratory and diagnostic testing, evaluating results, utilization patterns, as well as quality and efficiency metrics.

• Participate in the development, implementation, evaluation, and revision of clinical pathways and tools.

• Educate multidisciplinary teams and physicians on clinical pathways, protocols, and managed care principles.

• Collaborate with leadership to design, implement, and evaluate a centralized care model.

• Monitor clinical and financial indicators, taking action to achieve continuous improvement.

⛳️ Requirements

• Associate’s Degree in Nursing with seven years of clinical experience in a healthcare setting, or a Bachelor’s Degree in Nursing with five years of clinical experience in a healthcare environment.

• Valid Registered Nurse license issued by the state where services will be rendered, or a current multi-state RN license through the enhanced Nurse Licensure Compact.

• Completion of a state criminal background check and federal background check if applicable, as mandated for regulated areas.

• Acquire Basic Life Support certification within 30 days of hire.

• Prior experience in care coordination is preferred.

• Exceptional interpersonal communication and negotiation skills.

• Ability to engage with individuals from diverse social, economic, and cultural backgrounds.

• Flexibility, open-mindedness, and adaptability to changing circumstances.

• Capability to exercise independent judgment regarding patients’ psychosocial needs.

• Ability to work in both office and clinical environments.

• Position focuses on the D-SNP program; occasional travel may be required.

🏝️ Benefits

• Competitive salary and comprehensive benefits package.

• Opportunities for professional development and continuing education.

• Supportive work environment that values diversity and inclusion.