Care Coordinator, RN

About the role

Alpine Physicians is hiring a registered nurse Care Coordinator in Denver to deliver care coordination services within its primary care practice setting. The role supports members who are at risk or face barriers to healthcare, with a focus on member-centered care planning and care management.

Key responsibilities

• Perform comprehensive assessments and develop, communicate and implement care plans with members, caregivers, providers and care teams
• Provide episodic and longitudinal care planning, monitor acute facility stays and discharges, and refer members to community resources
• Facilitate disease education groups and individual education, and help members build self-management skills
• Communicate assessment findings, care plan goals, interventions and outcomes to primary care providers in a timely manner
• Take part in care rounds and other practice meetings, and collaborate with providers on high-risk members
• Identify members who could benefit from care coordination using data sources such as high-risk and utilization reports, prior authorizations, referrals and EMR stratification
• Complete visits with members, caregivers and family in various settings, use behavioral health screening and motivational interviewing, and refer to community resources
• Document member information and interventions in care management software following standard operating procedures, and contribute to Lean and quality improvement activities

Required profile

• RN with a valid license in good standing; licensure must be maintained per company policy
• At least one year of case management experience, or a combination of relevant healthcare or behavioral health experience
• Preferred: experience with high-risk DSNP, CSNP complex members and Medicaid
• Experience helping patients navigate care transitions and managing psychosocial issues with patients and families
• Ability to work with diverse populations and provide culturally sensitive coaching and education

Required skills

• Case management and knowledge of community resources and agencies
• Motivational interviewing
• Behavioral health screening and referral
• Conflict management and problem resolution