Reports To: Manager of Care Coordination

Location: Remote - Must Reside in Colorado

Position Pay Range: $32.01 - $43.21

Status: Hourly/Non-Exempt 

Supervisory Role: None

Benefits include: Medical, Dental, Vision, 401k, FSA, Paid Hours Off, Paid Holidays, Group Discounts, Life & LTD, EAP

Position open until 4/8/2024 or until filled.

We don’t fill positions, we hire individuals…

Our culture is important and ensuring we have the right staff is critical. We encourage employee growth, provide learning opportunities, and often promote from within. Are you dependable, empathetic, and have an excellent work ethic? If so, you might be a good fit for us! 

About Western Healthcare Alliance (WHA)

Western Healthcare Alliance (WHA) began in 1989 when a small group of rural Colorado hospitals decided that there was power in numbers. Today, WHA has 30 healthcare members in Colorado and Utah. Of these 30 members, 20 own Healthcare Management, a separate entity, that provides revenue cycle solutions to healthcare entities. Developing and managing a menu of member-owned and partner programs, WHA saves members money that helps them remain sustainable and viable in their communities.

About WHA’s Community Care Alliance (CCA)

In August 2013, WHA began a journey to examine trends regarding the transition from traditional fee-for-service cost-based reimbursement systems to value-based payment models. Value-based payment models reward healthcare providers for meeting predetermined performance measures related to quality, efficiency and total cost of care. For most healthcare providers, this meant a significant change in how they delivered care. As a result, WHA’s vision was to create an organization to bridge that transition and focus on three goals: to build a common supportive infrastructure, to learn and share best practices, and to enhance their ability to perform in a value-based environment.

In March 2015, WHA formed Community Care Alliance, LLC. The CCA is a rural value-based clinically integrated network that engages in value-based payment models that serves payer populations including Medicare, commercially insured, self-funded domestic (WHA member covered lives) and self-funded community employers. The CCA staff provides management and oversight of the contractual arrangements with payers and offers the following population health management support services to participants:

• Population Health Data Analytics Platform
• Care Coordination Education & Training
• Quality Improvement Coaching
• Quality Reporting Assistance
• Data Analytics Training
• Health Policy & Regulation Guidance

REGIONAL CARE COORDINATOR (RN)

Position Summary

The Regional Care Coordinator is responsible for growth and maintenance of the care coordination program which includes recruitment and maintenance of patients enrolled in care management services; assurance of the completion of the annual wellness visit and follow up on all elements of the preventative plan of care; and discussing advance care planning with patients. These responsibilities will be completed by providing outreach, disease management/care management, care coordination/health promotion, education/training and motivational support to patients, referral sources and the community. This position will work to improve the quality of life of patients enrolled through supporting quality outcomes, smooth care transitions, coordination of care across the health continuum, encourage healthy lifestyle choices to reduce long term effects of chronic illness. This position is accountable for working with and representing our clinics across multiple constituents. This position reports to the Director of Clinical Improvement.

General responsibilities include:

• Work collaboratively with clinic staff to provide education and recruitment techniques.
• Exhibit competence in the Seven Domains of Care Coordination in the primary care setting:
  • Population Health Management,
  • Comprehensive Assessment and Care Planning,
  • Interpersonal Communication,
  • Education/Coaching,
  • Health Insurance and Benefit knowledge,
  • Community Resource knowledge and
  • Research and Evaluation skills.
• Provide outreach, disease management, education and other needed clinically based activities to patients managing various chronic health conditions and to referral sources and community.
• Assess and identify participant’s readiness, willingness, and ability to change.
• Identify patient coaching, support, and educational needs by focusing on what is important to their quality of life.
• Determine and connect with relevant community and/or health care resources to support solutions; provide educational tools to promote self-management.
• Collaborate with the patient to develop interventions and sets goals for behavioral modification within the scope of nursing practice.
• Conduct health and wellness coaching sessions to assist participants in making lasting changes to their health and wellness.
• Monitor and document the patient’s progress toward his or her optimal level of wellness.
• Promote wellness and provides education regarding preventative care measures.
• Act as a liaison between referral sources, facilities, and outside entities to prevent and/or resolve continuum of care issues
• Communicate with service delivery partners, providers, and other health professionals to provide care coordination to ensure the plan of care facilitates the efficient use of health care resources.
• Demonstrate skills in effectively coordinating and monitoring care to promote quality and cost-effective outcomes.
• Proactively follow up with patients discharged from all hospitals, rehab facilities and emergency rooms to recruit patients into the care management services to ensure patient has an appointment with their provider and reviews any unmet needs prior to the upcoming appointment.
• Analyzes clinical data generated from EHR/Registry system and identifies patients who have gaps in care and utilizes risk stratification intervention metrics for care coordination recruitment purposes.
• Assist clinics with billing questions related to services provided by Regional Care Coordinator.

Remains current on industry trends, best practice operational models, and changing patient and provider needs.

Residence Location:

The employee must live within the Western Slope region of Colorado and be within day-trip driving distance of many of our member practices and hospitals to allow for in-persons visits.

Competencies

To perform the job successfully, an individual should demonstrate the following competencies:

• Must be able to work collaboratively with diverse individuals at all levels of the CCA organization and external customers.
• Requires a general knowledge of business, healthcare and healthcare coverage issues.
• Notable experience with data analytics and electronic medical record systems
• Notable experience with value based contracting and networking and healthcare policy.
• Ability to think creatively and provide office management oversight.
• Ability to simultaneously manage multiple projects with tight schedules.
• Ability to work independently and as part of a team.
• Good verbal and written communication skills, including the ability to do group presentations and work one-on-one.
• Current driver’s license and ability to travel, including some overnight stays.

Qualifications

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Education/Experience:
• Unencumbered Registered Nurse in the State of Colorado
• 2-3 years primary care clinical experience including working with the geriatric population preferred
• Previous work experience with educating patients and patient goal setting preferred
• Previous work experience in an autonomous position

Language Skills:The ability to converse in English and Spanish is preferred. Ability to read, analyze, and interpret common scientific and technical journals, financial reports, and legal documents. Ability to respond to common inquiries or complaints from customers, regulatory agencies, or members of the business community. Ability to write policies and procedures that conform to prescribed style and format. Ability to effectively present information to top management, public groups, and/or boards of directors.

Mathematical Skills:
Ability to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals. Ability to compute rate, ratio, and percent and is knowledgeable in metric, apothecary and household measurements and can convert from one system to another.

Reasoning Ability:

Ability to solve practical problems and deal with a variety of concrete variables in situations where only limited standardization exists. Ability to interpret a variety of instructions furnished in written, oral, diagram, or schedule form. Ability to modify care based on the developmental / functional age of the patient as well as that of the patient's ethnic background.

Age Specific:

Must be able to provide care according to the developmental level and or chronological patient served. This includes, but is not limited to, identifying the needs and abilities of each patient, and demonstrating an understanding of how a patient’s chronological and developmental age influences his/her need for adaptations related to his/her abilities. Also, an understanding of how a patient’s age impacts his/her ability to deal with and adapt to the care needed/provided is required. General census of neonatal to geriatric patients.

Other Skills and Abilities:

Ability to act as a patient advocate. Ability to interact with patients, families, visitors, and co-workers. Ability to interact assertively and tactfully when dealing with conflict and in group solving activities. Ability to demonstrate a professional, open minded approach in identifying problems and resolving problems/conflicts. Ability to develop creative solutions outside of the health care setting. Ability to develop relationships with community resources. Ability to appropriately manage time and work in flexible environments. Ability to work autonomously and meet demanding deadlines.

Supervisory Responsibilities:

This job has no supervisory responsibilities.

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.
• The employee is subject to inside and possibly outside weather conditions.
• The employee is also subject to exposure to blood and body fluids, proximity to moving mechanical parts, electrical shock, exposure to burns and radiant energy, exposure to explosives, exposure to toxic chemicals and biological agents.

The employee will have a flexible work environment with a combination of work performed in the primary care and specialty clinics with some interactions in the hospital setting as well.

Remote Work Environment:

The employee must maintain patient confidentiality at all times and ensure remote locations such as home office or travel locations where patient interactions occur meet privacy standards. The employee will be provided with necessary equipment to work remotely such as computer, mobile phone, and other technologies as needed.

Residence Location:

The employee must live within the Western Slope region of Colorado and be within day-trip driving distance of many of our member practices and hospitals to allow for in-persons visits.