The Population Health Coordinator is the link between Tapestry 360 Health (Tap360), patients, other health care services, and community-based organizations. They work alongside patients, assessing their needs for improved health, reducing barriers to health care access, and working to close gaps in clinical care, with an aim toward improving patient health outcomes at the individual and population health levels. Furthermore, they partner with patients to provide disease-specific health education and connects patients with resources for unmet social needs.

Essential Duties and Responsibilities:

• Provides peer support and advocacy for patients navigating the health care system and builds relationships with patient, family and other individuals, as well as health care team staff and community organizations.
• Assesses social drivers of health for patient population, and connects patients to resources for unmet social needs
• Communicates with patients regarding scheduled appointments and follow-up visits. Assists patients in obtaining primary care, specialty care and ancillary services. Reports identified health care challenges to their manager.
• Enrolls eligible patients in disease management program(s) and provides disease-specific and preventive care patient education according to program requirements.
• Monitors patients at required frequencies and tracks clinical outcomes as indicated.
• Collaborates, coordinates, and communicates with clinical care team members to resolve outstanding patient care related items, better facilitate care delivery, and facilitate treatment plan changes in consultation with the primary care provider, including includes preparing for and participating in regularly scheduled caseload oversight with clinical staff, as applicable.
• Enters and maintains electronic medical records, compiles reports and completes other program documentation.
• Facilitates transitions of care for patient, including between specialty and inpatient/outpatient settings. When required, obtains medical records from other organizations involved in patient care.
• Supports population health and quality improvement efforts, including conducting outreach and education to targeted populations of patients to close care gaps.
• Other duties may be assigned.

Qualifications:

Required Education and/or Experience :

• A minimum of two years of healthcare or public health experience is required.
• Experience with electronic medical record systems and Microsoft Office is required.
• High school diploma or GED required

Preferred Education and/or Experience :

• Associate’s or bachelor’s degree is preferred.

Language Skills :

• Fluency in languages in addition to English is a plus.

Competencies :

• Familiarity with and/or ability to learn how to use Microsoft Office and G suite.
• Ability to use computers, laptops, and cellphone apps.
• Ability to initiate and lead conversations with people from different backgrounds, and engage patients in a therapeutic relationship, when appropriate, by telephone or face-to-face.
• Demonstrated problem solving and critical thinking skills as well as ability to effectively work as part of a team and practice cultural humility.
• Knowledge about current health equity issues.
• Passion for helping others
• Punctual, reliable, and willing to learn
• Strong interpersonal skills, communication skills and confidence and persistence in seeking out providers’ time to review patient progress.
• Experience with or ability to learn assessment tools and interventions for hypertension, diabetes and mild to moderate depression.
• Ability and opportunity to work flexible hours.

Additional Qualifications:

• Lived experience navigating barriers to care within the healthcare system