We are recruiting for a Transition Care Coordinator, Denver Health MedicalPlan to join our team!

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　　DepartmentManaged Care Administration

　　Remote Opportunity. Must Be a Colorado Resident

　　Job Summary

　　Under general supervision, the Transition Care Coordinator (RNCC) isresponsible for facilitating and coordinating the care delivered to anassigned group of members through multidisciplinary and member/familycollaboration to ensure quality and cost effective outcomes are deliveredwithin appropriate care coordination parameters. Coordination involvesassessment, planning, support, and evaluation of member care and relatedoutcomes. Activities to be performed are screening and assessment ofmedical, behavioral health and social determinants needs and gaps in care,collaboration with the Member to develop a care plan with SMART (SMART goalsare: Specific, Measurable, Attainable, Relevant and Timely) goals,periodic outreach within defined timeframes to support member in achievingtheir goals and supporting the Members self-efficacy to navigate systems. RNCCcommunicates closely with the Member's care team inclusive of: themember, the member's designated health representatives, primary careprovider, behavioral health providers and other care coordinators involvedwith

　　Essential Functions:Use DHMP Care Management protocols and critical thinking to assess, identifyopportunities to improve Member healthcare outcomes, collaboratively setSMART goals with the Member, develop a care plan with interventions andsupport and enable the Member to achieve their goals and independentlynavigate needed services to improve overall health outcomes. (10%)Visit members with complex needs in community based settings, includingcommunity centers, hospitals or providers' offices. (10%)Provide a complete continuum of quality care through close communication withmembers via in-person, phone or electronic interaction. (10%)Support members with education relevant to their disease process, medicationreviews and connections to community resources such as food, housing orfinancial support programs. (10%)The RNCC will work with members with complex needs, prioritize caremanagement and work with a multidisciplinary team to support the needs of theMembers on their caseloads. (10%)Document in readable, understandable language according to professional,regulatory, and agency standards. (10%)Document and disseminate results of care to member, caregivers, and othersinvolved in the care or situation, as appropriate, in accordance withcontractual requirements, state and federal laws, regulatoryrequirements, and Denver Health policy. (10%)RNCC will be responsible for a defined caseload of Members identified asneeding Complex Care Management (CCM) or Population HealthManagement/Disease Management (PHM) services. (10%)Members meet the threshold for CCM by meeting defined threshold conditions,including multiple chronic physical health and/or behavioral healthconditions, polypharmacy, high costs of care, avoidable use of high costservices and/or associated social health disparities. (10%)Members meet the threshold for PHM by having at least one of several definedconditions, including a chronic physical or behavioral health condition,like diabetes or depression; a person with special health care needs;high-risk pregnancy or other identified condition. (10%)

　　Education:Bachelor's Degree Nursing Required

　　Work Experience:Two years of clinical experience in a hospital, acute care, homehealth/hospice, direct care or case management required RequiredTwo years of experience in care coordination or case management r quiredRequired

　　Licenses:RN-Registered Nurse - DORA - Department of Regulatory Agencies Required

　　Knowledge, Skills and Abilities:Must have reliable transportation to travel to community-based locationswithin the Denver-metro area.Bilingual ability English/Spanish.Problem solving skills; the ability to systematically analyze problems,draw relevant conclusions and devise appropriate courses of action.Ability to communicate verbally and in writing complex or technicalinformation in a manner that others can understand, as well as ability tounderstand and interpret complex information from others.Knowledge of health plan case management, care coordination, or membernavigation.Medicaid and Medicare Managed Care knowledge.Skills working with the needs of vulnerable populations who have chronic orcomplex bio-psychosocial needs.Knowledge and understanding of case management/coordination of careprinciples, programs, and processes in either a hospital or outpatienthealthcare environment.Ability to collaboratively support team members and/or staff to achievepre-determined goals. Effectively collaborate with and respond to variedpersonalities in differing emotional conditions, and maintain professional