Disease Management Coordinator in Granger, Indiana at Beacon Health System

Reports to the Director of Care Coordination. The Disease Management Coordinator is a system-level clinical expert and clinical integration leader accountable for advancing the development, implementation, performance monitoring and continuous improvement of standardized, evidence-based care pathways for defined disease-specific patient populations across Beacon Health System. The role works with providers, clinical leaders, educators, Quality, certification and accreditation partners and interdisciplinary teams to ensure care pathways are consistently designed, communicated, implemented, maintained and evaluated from acute presentation through discharge, transition and ambulatory follow-up.

The Disease Management Coordinator provides system-level clinical and operational expertise, leads multidisciplinary pathway initiatives, evaluates program performance, identifies opportunities to reduce unwarranted care variation and recommends actions to improve clinical outcomes, utilization, readmissions, patient transitions and process reliability. This key role builds and sustains the structures that enable frontline teams, providers and clinicians to deliver reliable best-practice care, including communication channels, councils and committees, staff education, pathway updates, certification processes, workflows, escalation routes and cross-setting handoffs. This position serves as a bridge between clinical evidence, provider practice, organizational policy, performance information and frontline workflows to support consistent care delivery.

MISSION: We deliver outstanding care, inspire health, and connect with heart.

VALUES: Trust. Respect. Integrity. Compassion.

SERVICE GOALS: Personally connect. Keep everyone informed. Be on their team.

Leads system-wide Disease-Specific Care pathway integration by:

• Serving as the system-level clinical integration lead and subject-matter resource for assigned Disease-Specific Care populations across hospital and post-acute settings.
• Leading multidisciplinary development, implementation, standardization and ongoing optimization of evidence-based care pathways in partnership with physician leaders, clinical operations, nursing, Care Coordination, Case Management, pharmacy, Quality, education and ambulatory teams.
• Aligning evidence-based clinical practice expectations across acute, discharge, transition, post-acute and ambulatory workflows, with clear assignment of responsibilities to appropriate disciplines and operational owners.
• Translating care-pathway expectations into sustainable workflows, documentation standards, order sets, consult and referral processes, education and communication mechanisms in partnership with responsible departments.
• Identifying care variation, duplication, communication gaps, workflow barriers and handoff risks and leading multidisciplinary efforts to resolve identified issues.
• Evaluating changes in clinical best-practice evidence, regulatory requirements, certification standards, organizational priorities and patient-population trends and recommending corresponding pathway or workflow changes.

Leads implementation, governance and organizational readiness by:

• Serving as the clinical integration lead for assigned Disease-Specific Care populations within applicable councils, committees, workgroups and governance structures.
• Developing and presenting evidence-based recommendations regarding clinical practice, pathway priorities, implementation barriers and improvement opportunities to providers and organizational leaders.
• Leading implementation and sustainment of approved pathway changes across affected departments, entities and care settings, including identification of stakeholders, dependencies, readiness needs and escalation pathways.
• Coordinating communication of pathway decisions, changes and performance expectations across hospital entities, provider groups and ambulatory teams.
• Developing and delivering staff and provider education in collaboration with clinical education, subject-matter experts, Quality and other responsible departments.
• Providing clinical consultation, coaching, at-the-elbow support and expert review of patient-specific scenarios to support pathway adoption and reliable practice.
• Monitoring implementation progress and adoption, addressing barriers and escalating unresolved clinical or operational risks to the appropriate leader or governance body.

Leads clinical performance analysis and continuous improvement by:

• Establishing and monitoring meaningful clinical, utilization, readmission, process and pathway-reliability indicators for assigned Disease-Specific Care populations in collaboration with Quality, clinical, operational and data partners.
• Analyzing and interpreting available performance information to identify care variation, outcome trends, utilization concerns, process weaknesses and improvement opportunities.
• Translating performance findings into actionable recommendations, improvement priorities and corrective actions for consideration by clinical and operational leaders.
• Evaluating whether pathway interventions and workflow changes achieve expected clinical and operational outcomes and recommending modification or escalation when performance does not meet established expectations.
• Benchmarking program practices and performance against applicable clinical guidelines, certification requirements, external standards and peer practices when reliable comparative information is available.
• Presenting program performance, identified barriers, recommended interventions and implementation progress to appropriate providers, councils, committees and leaders.

Leads certification, accreditation and program sustainment by:

• Partnering with Quality, regulatory, accreditation and certification stakeholders to incorporate required Disease-Specific Care processes, documentation, education and workflow elements into standard operations.
• Coordinating certification and accreditation readiness activities, including program assessment, evidence collection, education, workflow review and corrective-action planning.
• Identifying program gaps, coordinating corrective actions with responsible owners, monitoring completion and escalating unresolved risks or barriers.
• Maintaining current pathway resources, standards, workflows and reference materials to provide a consistent source of operational guidance.
• Providing clinical leadership and mentorship to clinicians, educators and other stakeholders involved in assigned Disease-Specific Care pathways.
• Promoting shared accountability for evidence-based practice, clinical reliability and consistent patient transitions across Beacon Health System.

Performs other functions to maintain personal competence and contribute to departmental effectiveness by:

• Completing other job-related assignments and projects as directed.
• Maintaining current knowledge of clinical guidelines, disease-management practices, quality-improvement methods, regulatory expectations and emerging evidence applicable to assigned patient populations.

ORGANIZATIONAL RESPONSIBILITIES

Associate complies with the following organizational requirements:

• Attends and participates in department meetings and is accountable for all information shared.
• Completes mandatory education, annual competencies and department-specific education within established timeframes.
• Completes annual employee health requirements within established timeframes.
• Maintains license, certification and registration in good standing.
• Consistently utilizes appropriate universal precautions, protective equipment and ergonomic techniques to protect patients and self, in accordance with infection-prevention policies.
• Adheres to regulatory agency requirements, survey processes and compliance expectations.
• Complies with established organizational and departmental policies.
• Is available to work overtime or additional or alternative shifts and schedules when required.

Education and Experience

• Baccalaureate degree in Nursing required.
• Master's degree in Nursing, healthcare administration, quality, public health or a related field strongly preferred. An equivalent combination of advanced clinical experience and demonstrated system-level program leadership may be considered, consistent with organizational requirements.
• An active Registered Nurse license in the state or states of practice is required and must be obtained before the start date.
• Minimum of three years of related clinical experience required.
• Experience leading multidisciplinary clinical integration, disease-management, quality-improvement, care-pathway, certification or system-level practice-change initiatives strongly preferred.
• Demonstrated experience using clinical and operational performance information to identify variation, recommend interventions and evaluate improvement outcomes preferred.
• Experience working across multiple departments, clinical disciplines, entities or care settings preferred.

Knowledge & Skills

• Requires comprehensive knowledge of clinical care practices, chronic and acute disease management, transitions of care and evidence-based practice.
• Requires the ability to translate clinical guidelines, regulatory requirements and best practices into standardized workflows and operational expectations.
• Requires the ability to provide system-level clinical leadership and influence practice across departments, disciplines, entities and care settings without reliance on direct supervisory authority.
• Demonstrates advanced facilitation, change-management, program leadership, education, project coordination and interdisciplinary collaboration skills.
• Demonstrates strong analytical and critical-thinking skills, including the ability to compile, validate, interpret and communicate clinical, utilization, readmission and process information.
• Demonstrates the ability to identify meaningful performance indicators, evaluate trends, determine potential contributing factors and translate findings into actionable recommendations.
• Demonstrates knowledge of performance-improvement methods and tools used to evaluate clinical processes, reduce variation and sustain change.
• Demonstrates the ability to lead multidisciplinary teams and move complex decisions from recommendation through implementation, monitoring and sustainment.
• Demonstrates clear and effective written, verbal, presentation and listening skills, with the ability to communicate with frontline staff, providers and leaders.
• Demonstrates the ability to prepare and present concise, evidence-based recommendations to clinical, operational and executive audiences.
• Requires working knowledge of regulatory, accreditation and certification concepts relevant to Disease-Specific Care programs.
• Requires working knowledge of clinical performance measurement, data integrity, benchmarking, program evaluation and outcome monitoring.
• Demonstrates computer literacy and effective use of the electronic health record, word-processing, spreadsheet, presentation and available clinical reporting software.
• Requires the ability to independently prioritize multiple system-level initiatives and maintain reliable follow-through across departments and entities.
• Requires independent judgment in evaluating complex clinical and operational issues, developing recommendations, determining appropriate escalation and coordinating multidisciplinary action.
• Requires the ability to adapt to changing workflows, priorities, evidence and patient populations and to redirect work in response to organizational priorities and population trends.
• Demonstrates organizational awareness necessary to build consensus, address competing priorities and advance change across complex clinical environments.

Working Conditions

• Works primarily in clinical, office and meeting environments across Beacon Health System, with regular interaction across hospital and ambulatory settings.
• Frequent changes in priorities and project demands are expected.
• System travel is required.
• Work activities may require schedule flexibility to support provider engagement, implementation activities, certification readiness and operational needs across entities and care settings.

Physical Demands

• Requires the physical ability and stamina to perform the essential functions of the position.
• Clear communication and speaking voice for meetings, presentations, education and telephone or virtual communication are required.