Disease Management Population Health Weirton

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The Disease Management Coordinator collaborates with patients and primary care providers to ensure patients receive quality, efficient, and cost-effective healthcare services. Coordinates, monitors, and evaluates all options and services to optimize a patient’s health status. CORE DUTIES AND RESPONSIBILITIES: The statements described here are intended to describe the general nature of work being performed by people assigned to this position. They are not intended to be constructed as an all-inclusive list of all responsibilities and duties. Other duties may be assigned.

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. Works collaboratively with patients to design an individualized plan of care that ensures coordination of services by the healthcare team. Collaborates with available social services for appropriate resource and financial management which may include, but is not limited to financial assistance coordination/referrals, entitlement program coordination/referrals, patient benefit coordination, assessment for appropriate usage of Health Care Resources/clinical cost efficiency. 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, including fiscal, clinical and patient satisfaction data Implements clinical interventions based on risk stratification and evidence-based clinical guideline adherence and promotes best practice by initiating/adjusting therapies as directed by the practitioner and providing appropriate follow-up monitoring as needed. Coordinates appropriate laboratory and diagnostic testing. Continuously evaluates laboratory results, diagnostic tests, utilization patterns and other metrics to monitor quality and efficiency results for assigned population Participates in development, implementation, evaluation and revision of clinical pathways and other tools. Educates the multidisciplinary team and physicians about clinical pathways/protocols and managed care principles Works with leadership to design, implement, and evaluate a centralized care model that optimizes value. Works with leadership to continuously evaluate process, identify problems, and propose process improvement strategies Monitors clinical and financial indicators on an ongoing basis and takes action to achieve continuous improvement in both areas.