Job description

Description: SUMMARY:
The Population Health Care Coordinator will play a key role in assisting patients with achieving improved health outcomes. Using Population Health management strategies, the care coordinator will utilize patient registries of target populations to ensure patients receive necessary follow-up care in managing their health more effectively. The Population Health Care Coordinator will function within a team-based care model, working closely with members, including providers, nurses, medical assistants, and clinical and social service case managers. They will reach out to patients who need preventive care appointments and screenings and patients with chronic diseases and other conditions that impact their necessary and routine health maintenance. The Population Health Care Coordinator will also support the agency's priorities related to quality improvement initiatives and performance-based contracts and help achieve benchmarks in quality of care.
GENERAL DUTIES & RESPONSIBILITIES:

• Participates in Population Health and primary care team meetings and quality improvement initiatives.
• Assists all patients through the healthcare system by acting as a patient advocate and navigator.
• Evaluates clinical care, utilization of resources, and development of new clinical tools, forms, and procedures.
• Participates in a team for data collection, health outcomes reporting, clinical audits, and programmatic evaluation related to Patient-Centered Medical Home (PCMH) and value-based care initiatives.
• Promotes clear communication amongst a care team and treating clinicians by ensuring awareness regarding patient care plans.
• Conducts comprehensive, preventive screenings for patients and/or assists all support staff in daily patient interactions as needed.
• Performs other duties as needed.

Requirements: Education: Bachelor’s degree required. (Two years’ experience in healthcare or health-related field involving data management and/or patient outreach/navigation experience can substitute for a degree.)
Experience:

• Able to learn new technologies quickly, including EHR (OCHIN/EPIC) documentation workflows and reporting functions
• Strong critical thinking skills
• Organized; able to prioritize effectively
• Excellent verbal and written communication skills
• Able to collaborate effectively with various care team members
• Highly motivated; commitment to improving population health and advancing health equity required
• Ability to work with a diverse patient population
• Bilingual Spanish and/or Portuguese/Cape Verdean is highly preferred

Software/Hardware: Must be proficient and have a strong working knowledge of Microsoft Office (Outlook, Excel, Word, etc.).

Job Type: Full-time

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