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Department

Job Summary

Under general supervision the Transition Care Coordinator (RNCC) is responsible for facilitating and coordinating the care delivered to an assigned group of members through multidisciplinary and member/family collaboration to ensure quality and cost effective outcomes are delivered within appropriate care coordination parameters. Coordination involves assessment planning support and evaluation of member care and related outcomes. Activities to be performed are screening and assessment of medical behavioral health and social determinants needs and gaps in care collaboration with the Member to develop a care plan with SMART (SMART goals are: Specific Measurable Attainable Relevant and Timely) goals periodic outreach within defined timeframes to support member in achieving their goals and supporting the Members self-efficacy to navigate systems. RNCC communicates closely with the Members care team inclusive of: the member the members designated health representatives primary care provider behavioral health providers and other care coordinators involved with the Members care.

Essential Functions:

• Use DHMP Care Management protocols and critical thinking to assess identify opportunities to improve Member healthcare outcomes collaboratively set SMART goals with the Member develop a care plan with interventions and support and enable the Member to achieve their goals and independently navigate needed services to improve overall health outcomes. (10%)
• Visit members with complex needs in community based settings including community centers hospitals or providers offices. (10%)
• Provide a complete continuum of quality care through close communication with members via in-person phone or electronic interaction. (10%)
• Support members with education relevant to their disease process medication reviews and connections to community resources such as food housing or financial support programs. (10%)
• The RNCC will work with members with complex needs prioritize care management and work with a multidisciplinary team to support the needs of the Members 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 others involved in the care or situation as appropriate in accordance with contractual requirements state and federal laws regulatory requirements and Denver Health policy. (10%)
• RNCC will be responsible for a defined caseload of Members identified as needing Complex Care Management (CCM) or Population Health Management/Disease Management (PHM) services. (10%)
• Members meet the threshold for CCM by meeting defined threshold conditions including multiple chronic physical health and/or behavioral health conditions polypharmacy high costs of care avoidable use of high cost services and/or associated social health disparities. (10%)
• Members meet the threshold for PHM by having at least one of several defined conditions 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:

• Associates Degree Nursing required

Work Experience:

• 1-3 years of clinical experience in a hospital acute care home health/hospice direct care or case management required required
• 1-3 years of experience in care coordination or case management required required

Licenses:

• RN-Registered Nurse - DORA - Department of Regulatory Agencies required

Knowledge Skills and Abilities:

• Must have reliable transportation to travel to community-based locations within 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 technical information in a manner that others can understand as well as ability to understand and interpret complex information from others.
• Knowledge of health plan case management care coordination or member navigation.
• Medicaid and Medicare Managed Care knowledge.
• Skills working with the needs of vulnerable populations who have chronic or complex bio-psychosocial needs.
• Knowledge and understanding of case management/coordination of care principles programs and processes in either a hospital or outpatient healthcare environment.
• Ability to collaboratively support team members and/or staff to achieve pre-determined goals. Effectively collaborate with and respond to varied personalities in differing emotional conditions and maintain professional composure at all times. Strong customer service orientation and aptitude required.

* This is a hybrid role with a weekly in-office requirement.

Shift

Work Type

Salary

Benefits

At Denver Health we take care of the people who take care of our community. Our benefits are built to support your life your family and your future with generous paid time off fully paid parental leave exceptional retirement contributions comprehensive health coverage and nationally recognized well-being programs. We invest in your growth through tuition assistance career advancement pathways and professional development while also offering meaningful financial advantages through loan forgiveness eligibility and employer contributions. When you join Denver Health youre joining a mission-driven organization that invests in you.

Here is a small list of our benefit programs:

• Paid time off starting at 28 days per year inclusive of vacation personal/sick and 7 Holidays

• 100% paid parental leave up to 6 weeks

• Immediate eligibility for retirement plans with employer contribution up to 9.5%

• Generous medical dental vision plans in addition to employer paid disability and life insurance.

• Comprehensive well-being programs including on-site employee fitness center located on Denver Health main campus and nationally recognized RESTORE Center

• Free RTD EcoPass (public transportation)

• Childcare discount programs & exclusive perks on large brands travel and more

• Tuition reimbursement & assistance

• Education coaching and professional development opportunities through the Workforce Development Center (WFDC) that support internal career growth and advancement pathways

• Professional clinical advancement program & shared governance

• Public Service Loan Forgiveness (PSLF) eligible employer free student loan coaching and assistance navigating the PSLF program

• National Health Service Corps (NHCS) and Colorado Health Service Corps (CHSC) eligible employer

About Denver Health

Denver Health is an integrated high-quality academic health care system considered a model for the nation that includes a Level I Trauma Center a 555-bed acute care medical center Denvers 911 emergency medical response system 10 family health centers 19 school-based health centers Rocky Mountain Poison & Drug Safety the Public Health Institute at Denver Health Denver Health Medical Plan and Denver Health Foundation.

As Colorados primary and essential safety-net health care system Denver Health is a mission-driven organization that has provided millions in uncompensated care for the uninsured each year.

Located near downtown Denver Denver Health is just minutes away from many of the cultural and recreational activities Denver has to offer.

Denver Health is an equal opportunity employer (EOE). We value the unique ideas talents and contributions reflective of the needs of our community. All job applicants for safety-sensitive positions must pass a pre-employment drug test once a conditional offer of employment has been made. Applicants will be considered until the position is filled.