Pop Health & Concierge Care Coordination, Care Coordinator- RN
23 days ago
Fort Lauderdale
Job Description Position Summary: The Population Health and Care Coordinator plays a critical role in overseeing chronic disease management, care coordination, complex case management, and programs aimed at improving quality of life and closing gaps in care for members within the manage care system. This position is responsible for coordinating, educating, and providing expertise to members across the continuum of care, from managing complex medical conditions to addressing chronic diseases. The coordinator promotes adherence to preventative care measures and facilitates healthcare interventions at the most appropriate and safe level, empowering members to self-manage their chronic conditions and take control of their health. This role supports the practitioner-patient relationship by aligning with the established plan of care, utilizing cost-effective and evidence-based practice guidelines. The primary objectives are to address acute healthcare needs, prevent or delay the progression of severe disease stages, and enhance the overall quality of life for members. Through this approach, the Population Health and Care Coordinator works to reduce complications, morbidity, and healthcare costs, ensuring that members receive comprehensive and coordinated care. The coordinator's responsibilities are carried out in accordance with the requirements of Medicaid contracts, Community Care Plan (CCP) Health Services policies and procedures, and Patient-Centered Medical Home (PCMH) standards, ensuring compliance with all relevant regulations and guidelines. By facilitating collaboration among healthcare providers, social services, and community resources, the Population Health and Care Coordinator plays a pivotal role in achieving positive health outcomes and improving the overall well-being of the members served. Essential Duties and Responsibilities: Lead and Coordinate Multidisciplinary Team Efforts: • Analyze clinical information to identify eligible members for the Concierge Care Coordination Program., • Conduct a thorough needs assessment for all identified enrollees, including risk stratification to determine health, psychological, educational, and social needs, and establish the level of care required., • Review daily census for hospitalized enrollees within the panel; assess needs and coordinate discharge planning., • Collaborate with physicians and enrollees to develop individualized care plans., • Establish Specific, Measurable, Achievable, Realistic, and Time-bound (SMART) goals that address identified needs, improve quality of life, and evaluate cost and quality outcomes., • Conduct outreach to enrollees with chronic conditions, multiple gaps in care, or those needing preventive services., • Provide education on disease processes, healthy lifestyle changes, and self-management of chronic conditions, consistent with clinical practice guidelines., • Educate members on shared decision-making tools to ensure they are informed of all care options, including potential benefits and risks., • Conduct outreach and follow-up for enrollees with frequent emergency room visits to identify contributing factors and develop strategies to reduce avoidable ER and hospital admissions., • Monitor clinical outcomes, ensure timely medical care, and promote adherence to recommended preventive care, screenings, and medication regimens., • Facilitate coordination, communication, and collaboration with members, providers, and other stakeholders to achieve care goals and optimize positive outcomes., • Conduct or participate in team huddles to review strategies, identify clients or providers with immediate needs, and develop action plans., • Maintain documentation requirements to meet compliance with quality standards and accreditation requirements related to disease management and care management programs., • Acknowledge and protect patient rights regarding confidentiality; adhere to HIPAA guidelines and regulations at all times., • Assist in conducting in-home assessments with Concierge Care Coordination Health Social Worker, as needed, to evaluate home safety, appropriateness of the setting, and ensure members have all necessary supplies and medications., • Support the practitioner-patient relationship and care plan with a focus on preventing disease exacerbation and complications. Qualifications: • Bachelor’s Degree in Nursing., • Registered Nurse licensure in the state of Florida Clinical Experience: • Proficient in Microsoft Office Suite and other relevant software for documentation and data management. Self-Motivation and Independence: • Exceptional oral and written communication skills, with the ability to clearly convey complex information to diverse audiences, including patients, healthcare providers, and team members., • Highly organized with excellent problem-solving abilities, capable of managing multiple priorities and tasks in a dynamic healthcare environment., • Strong analytical skills with the ability to read and interpret various documents, including safety rules, operating and maintenance instructions, and procedure manuals. Community Care Plan is currently following a hybrid work schedule. The company reserves the right to change the work schedules based on the company needs. Physical Demands: The physical demands outlined below are representative of those required for an employee to successfully perform the essential functions of this role. Reasonable accommodations may be made to enable individuals with disabilities to fulfill these essential functions. • Regular Activities: While performing the duties of this job, the employee is regularly required to sit for extended periods, use hands to handle or feel objects, tools, or controls, reach with hands and arms, and communicate verbally to effectively interact with team members and enrollees., • Frequent Activities: The employee is frequently required to stand, walk, and sit, which may involve moving between different areas of the work environment., • Occasional Activities: The employee may occasionally be required to stoop, kneel, crouch, or crawl to perform specific tasks or to access certain areas. The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of the job. The environment includes work inside/outside the office, travel to other offices, as well as domestic, travel. 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. We are an equal opportunity employer who recruits, employs, trains, compensates and promotes regardless of age, color, disability, ethnicity, family or marital status, gender identity or expression, language, national origin, physical and mental ability, political affiliation, race, religion, sexual orientation, socio-economic status, veteran status, and other characteristics that make our employees unique. We are committed to fostering, cultivating, and preserving a culture of diversity, equity, and inclusion. Background Screening Notice: In compliance with Florida law, candidates selected for this position must complete a Level 2 background screening through the Florida Care Provider Background Screening Clearinghouse. The Clearinghouse is a statewide system managed by the Agency for Health Care Administration (AHCA) and is designed to help protect children, seniors, and other vulnerable populations while streamlining the screening process for employers and applicants. Additional information is available at: