Disease Management Coordinator

Accountabilities: The Disease Management Coordinator will oversee care coordination activities for assigned patient populations, helping optimize health outcomes through proactive monitoring, education, advocacy, and collaboration with healthcare teams. This role focuses on identifying patient needs, implementing evidence-based interventions, and improving quality and efficiency across the continuum of care.

Coordinate, monitor, and evaluate healthcare services to support safe, effective, and cost-efficient patient care.

Identify high-risk patient populations and apply risk stratification methods to prioritize interventions and care management activities.

Collaborate with physicians, providers, patients, families, and multidisciplinary teams to develop and implement individualized care plans.

Support transitions of care by coordinating discharge planning, follow-up services, and communication between inpatient and outpatient care teams.

Provide patient education, advocacy, and support to encourage adherence to treatment plans and promote better health outcomes.

Manage care coordination activities for patients with chronic conditions, with a primary focus on heart failure management.

Monitor clinical, financial, and patient satisfaction metrics to identify opportunities for improvement.

Use healthcare data and performance indicators to guide decision-making and implement improvement strategies.

Apply evidence-based guidelines and clinical pathways to support appropriate interventions and follow-up care.

Coordinate laboratory testing, diagnostic evaluations, and ongoing monitoring of patient progress.

Partner with social services and community resources to assist patients with financial support, benefits coordination, and access to care.

Participate in the development and improvement of clinical programs, workflows, and care management models.

Educate healthcare teams on clinical pathways, quality initiatives, and managed care principles.

Requirements:

The ideal candidate is a licensed nursing professional with clinical experience and a strong interest in care coordination, chronic disease management, and improving patient outcomes. They should demonstrate excellent communication skills, clinical judgment, and the ability to collaborate effectively with diverse patient populations and healthcare teams.

Associate Degree in Nursing with 7+ years of clinical healthcare experience, or Bachelor’s Degree in Nursing with 5+ years of clinical healthcare experience.

Current Registered Nurse (RN) license in the state where services are provided, or an active multi-state RN license through the enhanced Nurse Licensure Compact (eNLC).

Bachelor’s Degree in Nursing preferred.

Prior experience in care coordination, disease management, utilization management, or population health preferred.

Ability to assess patient needs, develop care strategies, and make independent clinical decisions.

Strong interpersonal communication and negotiation skills when working with patients, families, providers, and healthcare teams.

Ability to work effectively with individuals from diverse social, economic, and cultural backgrounds.

Strong organizational skills with the ability to manage multiple priorities and complex patient cases.

Knowledge of evidence-based clinical practices, healthcare resources, and quality improvement principles.

Ability to obtain Basic Life Support (BLS) certification within 30 days of hire.

Completion of required background screening.

Benefits:

Full-time remote work opportunity.

Competitive compensation package.

Comprehensive healthcare benefits and wellness programs.

Opportunities for professional development and career growth.

Ability to make a direct impact on patient care and population health outcomes.

Collaborative environment with healthcare professionals across multiple disciplines.

Supportive workplace focused on quality improvement, innovation, and patient-centered care.

How Jobgether works: We use an AI-powered matching process to ensure your application is reviewed quickly, objectively, and fairly against the role's core requirements. Our system identifies the top-fitting candidates, and this shortlist is then shared directly with the hiring company. The final decision and next steps (interviews, assessments) are managed by their internal team. We appreciate your interest and wish you the best!  Why Apply Through Jobgether? 

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