Population Health Coordinator

Population Health Coordinator

Requirements

• MA or CNA preferred
• Knowledge of patient activation, motivational interviewing, chronic disease self-management, goal-driven care planning a plus
• Excellent computer skills and willingness to learn new software applications. Electronic health record experience and population health management tool experience a plus
• Familiarity with healthcare entities operating within the State
• Experience providing care to vulnerable populations
• Understanding of value-based healthcare, the ACO model, and population health fundamentals a plus
• Exceptional communication skills, both written and oral, ability to positively influence others with respect and compassion
• Strong work ethic built on a foundation of productivity, collaboration and teamwork
• Ability to manage multiple projects and activities with minimal supervision
• Demonstrated knowledge of continuous quality improvement techniques
• Regular and reliable attendance is an essential function of the job

Responsibilities

• Develops interdisciplinary care plan and other case management tools by participating in meetings; coordinating information and care requirements with other care providers; resolving issues that could affect smooth care progression; fostering peer support; providing education to others regarding the case management process.
• Monitors delivery of care by completing patient rounds; documenting care; identifying progress toward desired care outcomes; intervening to overcome deviations in the expected plan of care; reviewing the care plan with patients in conjunction with the direct care providers; interacting with involved departments to negotiate and expedite scheduling and completion of tests, procedures, and consults; reporting personnel and performance issues to director; maintaining ongoing communication with staff regarding variances from the care plan.
• Evaluates outcomes of care with the interdisciplinary team by measuring intervention effectiveness with the team; implementing team recommendations.
• Respects patients by recognizing their rights; maintaining confidentiality.
• Maintains quality service by establishing and enforcing organization standards.
• Maintains patient care database by entering new information as it becomes available; verifying findings and reports; backing up data.
• Maintains professional and technical knowledge by attending educational workshops; reviewing professional publications; establishing personal networks; benchmarking state-of-the-art practices; participating in professional societies.
• Contributes to team effort by accomplishing related results as needed.

Preferred Qualifications

No preferred qualifications provided.