Reports To: Manager of Care Coordination Location: Remote - Must Reside in Colorado Position Pay Range: $32.01 - $43.21 Status: Hourly/Non-Exempt Supervisory Role: None Benefits include: Medical, Dental, Vision, 401k Employer Match, FSA, Paid Hours Off, Paid Holidays, Group Discounts, Life & LTD, EAP

About Us In August 2013, Western Healthcare Alliance began a journey to examine trends regarding the transition from traditional fee-for-service cost-based reimbursement systems to value-based payment models. Value-based payment models reward healthcare providers for meeting predetermined performance measures related to quality, efficiency and total cost of care. For most healthcare providers, this meant a significant change in how they delivered care. As a result, our vision was to create an organization to bridge that transition and focus on three goals: to build a common supportive infrastructure, to learn and share best practices, and to enhance their ability to perform in a value-based environment.

In March 2015, we formed the CCA LLC. The CCA is a rural value-based clinically integrated network that engages in value-based payment models that serves payer populations including Medicare, commercially insured, self-funded domestic and self-funded community employers. The CCA staff provides management and oversight of the contractual arrangements with payers and offers the following population health management support services to participants:

Population Health Data Analytics Platform Care Coordination Education & Training Quality Improvement Coaching Quality Reporting Assistance Data Analytics Training Health Policy & Regulation Guidance

REGIONAL CARE COORDINATOR (RN)

Position Summary

The Regional Care Coordinator is responsible for growth and maintenance of the care coordination program which includes recruitment and maintenance of patients enrolled in care management services; assurance of the completion of the annual wellness visit and follow up on all elements of the preventative plan of care; and discussing advance care planning with patients. These responsibilities will be completed by providing outreach, disease management/care management, care coordination/health promotion, education/training and motivational support to patients, referral sources and the community. This position will work to improve the quality of life of patients enrolled through supporting quality outcomes, smooth care transitions, coordination of care across the health continuum, encourage healthy lifestyle choices to reduce long term effects of chronic illness. This position is accountable for working with and representing our clinics across multiple constituents. This position reports to the Director of Clinical Improv

General responsibilities include:

Work collaboratively with clinic staff to provide education and recruitment techniques. Exhibit competence in the Seven Domains of Care Coordination in the primary care setting: Population Health Management, Comprehensive Assessment and Care Planning, Interpersonal Communication, Education/Coaching, Health Insurance and Benefit knowledge, Community Resource knowledge and Research and Evaluation skills. Provide outreach, disease management, education and other needed clinically based activities to patients managing various chronic health conditions and to referral sources and community. Assess and identify participant's readiness, willingness, and ability to change. Identify patient coaching, support, and educational needs by focusing on what is important to their quality of life. Determine and connect with relevant community and/or health care resources to support solutions; provide educational tools to promote self-management. Collaborate with the patient to develop interventions and sets goals for behavioral modification within the scope of nursing practice. Conduct health and wellness coaching sessions to assi t participants in making lasting changes to their health and wellness. Monitor and document the patient's progress toward his or her optimal level of wellness. Promote wellness and provides education regarding preventative care measures. Act as a liaison between referral sources, facilities, and outside entities to prevent and/or resolve continuum of care issues Communicate with service delivery partners, providers, and other health professionals to provide care coordination to ensure the plan of care facilitates the efficient use of health care resources. Demonstrate skills in effectively coordinating and monitoring care to promote quality and cost-effective outcomes. Proactively follow up with patients discharged from all hospitals, rehab facilities and emergency rooms to recruit patients into the care management services to ensure patient has an appointment with their provider and reviews any unmet needs prior to the upcoming appointment. Analyzes clinical data generated from EHR/Registry system and identifies patients who have gaps in care and utilizes risk stratification intervention metrics for care coordination recruitment purposes. Assist clinics with billing questions related to services provided by Regional Care Coordinator.