Coordinator - The Longstreet Clinic - Population Health

Northeast Georgia Health System•Gainesville, GA

7d•Onsite

About The Position

The Population Health Coordinator is responsible for developing and monitoring care coordination processes and to provide support to the population health team for implementation of processes. The Population Health Coordinator will serve as a support role to the Care Managers as well as a liaison between the patient, family, and healthcare delivery team including inpatient facilities, emergency departments, and ancillary services.

Requirements

High School Diploma or GED.
Certified Medical Assistant. In lieu of CMA, 5 years of direct population health experience is required.

Nice To Haves

Ability to motivate people to participate in special programs
Ability to effectively communicate with physician office staff
Excellent interpersonal and customer service skills, including telephone etiquette

Responsibilities

Reach out and engage patients to facilitate care delivery coordination, care gaps, care needs; maintain daily call schedule
Outreach to low-risk patients during care transitions
Outreach to patients discharged from ED
Serving as a liaison between the patient, their family and their Longstreet Clinic care team
Assisting in data collection, management, and patient outreach as needed for target patient populations
Creating a positive experience for patients and families through courteous interactions via phone, patient portal and in-person, as well as appropriate and efficient routing and referrals to clinical staff or other practices when necessary
Work with Care Managers on quality improvement and meeting requirements for achieving/maintaining NCQA practice and provider recognitions for (but not limited to) Patient-Centered Medical Home, Diabetes Recognition and Heart/Stroke Care Recognition
Work with Care Managers reporting quality and performance improvement initiatives; establish and monitor performance goals goals and improving overall patient care metrics
Reporting to Population Health Manager productivity goals and performance
Participates in the development/review/revision of standard work and related policies and/or procedures for Care Manager services.
Attending and participating in regular meetings with the Population Health Team as well as within other departments (Clinical and Non-Clinical) and practices as needed
Actively participates in required offsite health fairs and other community events as assigned
Other duties as assigned/deemed necessary