Population Health Care Coordinator

The Population Health Care Coordinator works to improve health outcomes and quality metrics for specific patient groups by analyzing data, closing care gaps, and coordinating preventative care.

Responsibilities

· Patient outreach: Contact patients via phone, email, or mail to schedule overdue preventative screenings, chronic care visits, or general health care.

· Care Gap Closure: Identify and address gaps in care using electronic health record registries, health information exchanges, health plan reports, and state databases.

· Quality and Value-Based Tracking: Support clinical metrics tied to value-based care, HEDIS, Integrated Behavioral Health Homes, Primary Care Health Care.

· Interdisciplinary Collaboration: Work alongside primary care providers, clinical teams, IT staff and payers to align workflows and report performance trends.

· Documentation and Auditing: Maintain accurate patient tracking, record keeping and assist with compliance or payer audits.

· Increase continuity of care by supporting effective mechanisms in transitions of care and managing relationships with secondary and tertiary care providers and referrals

· Increase patients’ ability for self-management and shared decision-making

· Establish relationships with relevant community resources, resulting in the connection of patients to these resources with the goal of enhancing patient health and well-being, increasing patient satisfaction and reducing health care costs

· Assist in identifying appropriate QI initiatives to improve health outcomes for general Primary Care and Behavioral Health Care

· Facilitate, implement and evaluate QI activities to improve chronic care management among care teams

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Education/Experience

· High School/GED, Associate Degree or Bachelor’s degree in public health or related field -OR-

· 1 to 3 years healthcare experience, care coordination or quality management.

· Experience with quality metrics preferred

· Experience working with a diverse client population, including behavioral health, preferred

• Valid drivers license and automobile insurance coverage


• NVCI


• CPR (BLS)/First Aid