Registered Dietitian Care Coordinator - Denver Health Medical Plan (* Weekly Hybrid Schedule Requirement *)

Under general supervision, the Registered Dietitian is responsible for facilitating and coordinating the care delivered to an assigned group of members using multidisciplinary and member/family collaboration to ensure quality and cost effective outcomes are delivered within appropriate care coordination parameters.

Coordination involves assessment of care needs, planning, support, and evaluation of member care and related outcomes.

Activities to be performed are screening and assessment of medical, behavioral health and social determinants needs and gaps in care, collaboration with the Member to develop a care plan with SMART goals, scheduled outreach to support member in achieving their goals and supporting the Members self-efficacy to navigate systems.

Registered Dietitian communicates closely with the Member's care team inclusive of: the Member, designated health representatives, primary care provider, behavioral health providers and other care coordinators involved with the Member's care.

Encounters occur face to face, telephonically, and electronically with members in clinic and in other community-based settings.

Ensures appropriate nutritional counseling is provided to members.

Provides support to Care Management in role of dietitian on an interdisciplinary care team.

Utilizes Care Coordination Processes

Systematically collects focused data relating health needs and concerns of member, group, or population.

Establishes and maintains member-centered relationships.

Analyzes assessment data to determine opportunities for health promotion, health maintenance or health related problem needs and statements.

Identifies and executes evidence-based interventions to support the Member in achieving their health goals.

Identifies and works towards expected outcomes in a plan of care individualized for a specific member, group or population.

In collaboration with the Member, develops a care plan that identifies strategies and alternatives to attain expected outcomes. Utilizes competent, evidence based, telephone encounters and electronic communications according to regulatory requirements and standards, as well organizational policies and procedures.

Conducts systematic evaluation of outcomes of care coordination in relation to structures and processes prescribed by plan.

Documents in readable, understandable language according to professional, regulatory, and agency standards.

Documents and disseminates results of care to member, caregivers, and others involved in the care or situation, as appropriate, in accordance with contractual requirements, state and federal laws, regulatory requirements, and Denver Health policy. (25%) Provide Care Coordination Services

Coordinates the delivery of care within the clinic setting, throughout the organization, and across health care settings.

Provides relevant information across the care system, within Denver Health and with other healthcare systems and payers when member care is transferred between and among different specialties and/or within one or more organizations.

Provides information to the health care team including the member, family, and caregiver regarding available resources and benefits for health care services that ensures member choice and safe, timely transition.

Serves as point of contact within and among healthcare services and organizations.

Coordinates community resources.

Assures designation of primary responsibility among team members for each aspect of care plan, avoiding duplication and fragmentation.

Facilitates continuity of care using the multidisciplinary collaboration, and coordination of all appropriate healthcare services and community resources across the care continuum.

Orients member/caregiver to health care delivery system, services, access, and resources. (25%) Health Teaching and Promotion

Identifies barriers to goals and strategies to address.

Provides personalized education for optimal wellness.

Encourages preventative care such as immunizations and cancer screening.

Promotes appropriate utilization of resources.

Assists and educates caregiver when member is unable to participate.

Incorporates therapeutic communication, health literacy, cultural, and linguistic needs and preference into education and goals.

Supports members and caregivers in developing skills for self-efficacy to promote, maintain, or restore health such as healthy lifestyle tips, risk-reducing behaviors, age and developmental needs, daily living activities, and preventative care. (25%) Care Coordination

Responsible for a defined caseload of Members enrolled in the Medicaid Choice Programs who are identified as having a medium or low risk acuity level using data from a variety of sources, including the Member, their caregivers, providers, administrative claims data, pharmacy data and other inputs.

Provides nutritional counseling to patients as part of the Diabetic, Bariatric and Maternity programs.

Obtains Member consent to participate in the program as well as to share clinical information with the Member’s care team.

Works collaboratively with the Member to set SMART (specific, measurable, attainable, realistic and time-limited) goals and to graduate the Member to lower-intensity care programs and self-care within reasonable timeframes.

Works under the supervision and advice of the CM Manager who can provide insight into medical conditions, treatments, medications and answer medically-related questions as needed. (25%)