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.Position is an active contributor in the development of systems (e.g. work flows, clinical pathways, assessments) to improve the care of assigned member populations. Helps ensure compliance with state, federal and third party payor requirements.
1. 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.
2. 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.
3. 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.
4. 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 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.
5. Other duties as assigned.
Knowledge, Skills and Abilities
1. Bilingual in English/Spanish, preferred.
2. Knowledge of emotional and social factors that impact patient's health.
3. Excellent interpersonal skills.
4. Skilled in identifying problems/opportunities to improve care.
5. Ability to help the patient and family to understand, accept, and follow medical recommendations.
6. Ability to utilize resources, such as family or community agencies, to assist the patient to resume life in the community.
7. Knowledge of human nutrition in health and disease and its application to public health practices. Knowledge of nutrition, medication, and physical activity recommendations for individuals with diabetes and adults and children with diabetes.
Computers and Technology
1. Experience with Microsoft Office, required.
2. Ability to utilize programs for data analysis and data display, required.
3. Experience with Medical Management platforms used to document care coordination services, preferred.
Bachelor of Science degree in Nutrition or Dietetics from an Academy of Nutrition and Dietetics approved program, required. Master's Degree preferred
1. Registered Dietitian and comply with the requirements established and validated by the Commission on Dietetic Registration, required.
2. Specialty Certifications established and validated by the commission on Dietetic Registration, preferred.
3. Member of the Academy of Nutrition and Dietetics, preferred.
Location Denver Health Medical Plan
Work Type Full time
All job applicants for safety-sensitive positions must pass a pre-employment drug test, once a conditional offer of employment has been made.
Denver Health is an integrated, efficient, high-quality academic health care system that is considered a model for the nation. The Denver Health system includes the Rocky Mountain Regional Level I Trauma Center, a 525-bed acute care medical center, Denver's 911 emergency medical response system, 8 family health centers, 15 school-based health centers, the Rocky Mountain Poison and Drug Center, the Denver Public Health Department, an HMO, and The Denver Health Foundation.
As Colorado's primary safety net institution, Denver Health is a mission-driven organization that has provided more than $3.3 billion in care for the uninsured in the last ten years. Denver Health is a leader in performance and quality improvements and remains financially secure, in part, due to its nationally recognized implementation of lean principles in healthcare. Denver Health is a major resource to the community, serving approximately 185,000 individuals and 67,000 children a year.
Located just south of downtown Denver, Denver Health is just minutes away from many of the cultural and recreational activities Denver has to offer.
We strongly support diversity in the workforce and Denver Health is an equal opportunity employer (EOE).
"Denver Health is committed to provide equal treatment and equal employment opportunities to all applicants and employees. Denver Health is an Equal Opportunity Employer and does not discriminate against any employee or applicant for employment because of race, color, sex, age, national origin, religion, sexual orientation, gender identity, status as a veteran, and basis of disability or any other federal, state or local protected class."
Internal Number: 3091
About Denver Health
Take your career to the next level at Denver Health, where we offer a robust benefits package and endless opportunities for growth. Denver Health is a nationally-ranked, locally-trusted, premier healthcare institution located in the heart of Denver, Colorado.Twenty-five percent of all Denver residents, or approximately 150,000 individuals, receive their health care here. We are known as an integrated health care system that encompasses multidisciplinary academic specialties, a community health system, a level I adult trauma center, pediatric emergency and urgent care center home to Denver Public Health and many of the nation’s leaders in medicine.