Population Health Care Coordinator

The Population Health Care Coordinator works in collaboration and partnership within an interdisciplinary team to manage integrated healthcare conditions for patients with behavioral health and physical health/primary care needs. This role will focus on Patient Centered Care, quality improvement, comprehensive care management services, value based care, and closing care gaps. The Population Health Care Coordinator will ensure transparent whole person care and will support patient activation in care, improved population health outcomes and increased health literacy.

Duties of the population Health Care Coordinator include:

• Promote timely access to appropriate and encompassing care in compliance with standards set forth through HRSA and The Joint Commission.
• Promote adherence to a care plan, developed in coordination with the patient, primary care provider and care team
• Cultivate and support primary care and specialty provider co-management with timely communication, inquiry, follow-up and integration of information into the care plan
• 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
• Assess patient health literacy and utilize effective strategies to increase understanding and activation in care
• Anticipate and meet or exceed all patient needs.
• Collect and analyze population health outcomes and provide feedback for the improvement of the Care Coordination Program
• 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
• Increase efficiencies through the use of improved workflows and integration of service delivery to address complexity of chronic disease management.