Population Health Care Coordinator
Equitas Health
 Columbus, OH

POSITION SUMMARY:

The Population Health Care Coordinator works in collaboration and partnership within an interdisciplinary team to manage chronic healthcare conditions for patients with two or more chronic conditions and tangential issues. This role will focus on Patient Centered Medical Home (PCMH), 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. This position is responsible for facilitation of care coordination meeting, staff training, provider education and program design.

MAJOR AREAS OF RESPONSIBILITY:

  • Promote timely access to appropriate and encompassing care
  • Increase utilization of preventive care
  • Create and 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 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 and pro-actively takes responsibility for ensuring their quality care experiences
  • Assist with the identification of chronic care patients and add these to the patient registry
  • Attend all Care Coordinator training courses/webinars and meetings
  • Provide feedback for the improvement of the Care Coordination Program
  • Ensure that the data is entered accurately and consistently within the EHR
  • Partner with Quality and Evaluation department to identify appropriate QI initiatives to improve outcomes
  • Facilitate, implement and evaluate QI activities to improve chronic care management among care teams
  • Work with team members to develop step-by-step procedures for complex processes. Train staff in related policies and procedures.
  • Will participate in ongoing professional and personal development related to enhanced leadership activities and evidence-based practices
  • Other duties as assigned.

EDUCATION/LICENSURE:

Preferred: LPN, RN, LSW, LISW Licensed in Ohio

Required: Associate’s Degree in any discipline

KNOWLEDGE, SKILLS, ABILITIES AND OTHER QUALIFICATIONS:

  • Required: Minimum of 2 year’s experience working in a similar population health or patient education role
  • Knowledge of clinical quality indicators for Ryan White, FQHC, Meaningful Use and PCMH
  • 2-3 years of experience in a clinical setting
  • Evidence of essential leadership, communication and counseling skills
  • Highly organized with ability to keep accurate notes and records
  • Experience with Quality Improvement and change management preferred
  • Must have sensitivity to, interest in and competence in cultural differences, HIV/AIDS, minority health, and a demonstrated competence in working with persons of color, and LGBTQ communities.
  • Proficiency in all Microsoft Office applications and other computer applications required. Experience with EPIC highly preferred and ability to learn new technologies, web tools, and basic design tools is imperative
  • Knowledge of ambulatory care nursing principles or experience in an outpatient setting preferred
  • Must have reliable transportation and valid Ohio driver’s license

OTHER INFORMATION:

Background and reference checks will be conducted. Hours may vary, including working some evenings and weekends based on workload. Individuals are not considered applicants until they have been asked to visit for an interview and at that time complete an application for employment. Completing the application does not guarantee employment. In accordance with Equitas Health’s Drug-Free Workplace Policy, pre-employment drug testing will be administered. EOE/AA

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