Centura Health connects individuals, families and neighborhoods across Colorado and western Kansas with more than 21,000 of the most talented hearts and minds in medicine.
Through Centura Health’s 17 hospitals, two senior living communities, health neighborhoods, physician clinics, Flight for Life® Colorado, home care and hospice services, we offer a diverse range of work settings in a Colorado or Kansas community you will love to call home.
Enjoy amazing people, competitive pay, some of the best benefits in the industry and plenty of opportunity for professional growth and development.
If you’re ready to discover the difference of working for a fully-integrated health system with a non-profit, faith-based mission to care, we look forward to receiving your application.
Job Description/Job Posting ID: 95563
Recruiter Contact: Abigail Clothier, AbigailClothier@Centura.Org
Shift: Full Time, Exempt
Location: This position is located in the San Luis Valley - will require minimal travel
Provides care coordination to manage transitions of care for patients moving into and out of health care settings (including
but not limited to: emergency department, acute, post-acute, ambulatory, SNF, LTAC, Home Care, Hospice, IRF).
Coordinates communication and transfer of information between these settings; ensuring efficient and effective outcomes
and positive patient experiences. Works with Centura Health, the three local hospitals in the San Luis Valley, and other
partner organizations to develop and implement operational programs and processes that facilitate effective care
coordination across multi-disciplinary teams with specific focus on population management and post-acute transition
planning. Supports resource stewardship, collaborates in the development of, and applies evidence-based decision support
tools and applications to eliminate medically-unnecessary and duplicative services.
Minimum Education Requirements
Graduate of an accredited school of nursing (BSN preferred) or graduate of an accredited Master's in Social Work
Minimum Experience Requirements
Two or more years of professional nursing or social work experience.
Must demonstrate knowledge and competency in the following areas:
Ability to interact effectively and collaboratively with physicians, discharge planners, health care team members, individuals and members of their support systems
Familiarity with electronic health record systems and health information exchange
Third party payer payment methodologies
Proficient computer skills – data entry, Power Point, Excel, Word, retrieval and report generation
Navigating and accessing community and system resources
Effective interpersonal relations and bridge building skills
Written and verbal communications skills
Experience in process improvement initiatives
Experience in managed care, population health, case management or chronic disease management
Current Colorado RN license or LCSW license in good standing
■ Engages and works effectively with leaders, managers, and staff within Centura Health, the three hospitals in the
San Luis Valley and other partner organizations such as community programs that support patients and care
■ Develops and deploys training to case managers/discharge planners/hospitalists and other providers and staff to
enable most informed data being transmitted to patients and families.
■ Meets regularly with SLVCCC members to review, manage, and decide upon metrics. Achieve established goals
for population health and other outcomes as defined by SLVCCC.
■ Participates in evidence-based practice using current healthcare research findings and other evidence to expand
clinical knowledge, enhance role performance, and increase knowledge of professional issues.
■ Sponsors and facilitates care conferencing with acute care discharge planners and case managers, providers,
physicians, practice managers, etc., identifying best practice tools and processes to ensure effective patient
navigation between care settings, avoiding delays in timely placements and /or follow up.
■ Maintains , trains and educates others to achieve a comprehensive knowledge of post- acute care assets (local,
regional & state-wide) and how to effectively access these services.
■ Conducts outreach and networking efforts to establish and maintain positive working relationships to include but not
limited to : key physician practice managers, post-acute care providers, and acute care and post- acute
care leaders across the SLVCCC continuum.
■ Establishes and maintains ongoing communications with SLVCCC members, through regular meetings and
communications focused on finding solutions to issues in discharge of patients from the hospital to post-acute care
settings and assuring evidence-based practices throughout the care continuum.
■ Acts as the primary liaison for communication and collaboration on behalf of SLVCCC initiatives, ensuring
dissemination of pertinent information to those involved in care coordination across the continuum.
■ Works with SLVCCC HIE subcommittee and data and analytics support from each member facility to demonstrate
outcomes experienced as well as trends and opportunities.
■ Create reports monthly and on an ongoing basis to demonstrate goal performance including (but not limited to)
reductions in length of stay, hospital re-admissions, emergency room visits; and determinations of overall impact
through these interventions.
■ Adapts to rapidly changing technology as evidenced by demonstrating a practical competency in technology and
related equipment used care settings.
■ Analyzes data and providing reports through Power Point, Excel, Word, etc. in order to adequately demonstrate
■ Uses computers and information technology to document post-acute care patient transitions and interventions,
communicate progress to the care team, provide outcome reports to senior leadership and support decision-making.
■ Follows patients across the care and service continuum, as appropriate; works in tandem with cohort of staff in the
ambulatory, acute and post-acute environments, as well as community programs that support the patient and care
■ Assists patients in navigating the healthcare system, avoids delays in treatment, readmissions, and unplanned care
such as emergency department visits and hospital admissions.
■ Ensures patients and families have access to coaching and education regarding chronic disease self-management
and preventative health maintenance using predefined protocols and evidence based medicine.
■ Ensures accurate and timely information exchange to eliminate fragmentation, duplication, or gaps in care/health.
■ Identifies and understands third party billing/reimbursement methodologies.
■ Maintains objective, impartial working relationships with each member SLVCCC member organization.
☑ Medium Work - exert/lift up to 50 lbs. force occasionally, and/or up to 20 lbs. frequently, and/or up to 10 lbs.
Important notification to applicants as of Nov. 20, 2014: Effective Jan. 1, 2015, Centura Health will no longer hire tobacco users in Colorado and Kansas. The change to our policy does not apply to associates hired on or before Dec. 31, 2014. Centura Health is an Equal Opportunity Employer, M/F/D/V.