RN- Care Coordinator Transplant/ESRD

Coordinates and manages complex medical cases and health care needs across the continuum of care for both Medicare Advantage and Commercial members. Specific focus on members with transplant and End Stage Renal Disease (ESRD) diagnoses. Conducts member assessments, identifies gaps and interventions, and coordinates ongoing care with physician and integrated team. Develops initial and quarterly personalized care plan with member and the primary care provider (PCP). Maintains continuity of longitudinal documentation appropriate for continuity of care. Helps the member create / coordinate a support team in their local community to help them manage their long-term health status independently. Tracks the top coordination tasks needed by most complex cases and when they are completed will be graduating the member to monitoring status and / or other programs. Lead facilitator of the multidisciplinary care coordinator team managing and directing high-risk, high-cost members to appropriate resources, services and programs. Care Coordinators will focus on 1% commercial and 5% Medicare targeted/prioritized complex cases, subject to further analysis. Creates care plan summary and communicates / discusses with the PCP and member. Assigned to embedded locations or geographic areas / service areas. Know the Utilization Management (UM) and Care Coordination (CC) work flows. Build working relationships with providers for transplant concerns. Willing to learn the system for contracts and single case agreements for different insurance plans. Quote benefits related to transplants to members based on their plan. Perform On Call via a rotation schedule for the weekends to meet the regulatory guidelines for transplant members.