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 Bachelors 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

Required Experience:

IC