Population Care Coordinator

Capital Health (US)•Pike, NY

13d•$86,528 - $113,630•Hybrid

About The Position

The Population Care Coordinator (PCC) works on a multidisciplinary health care team in a primary care setting to understand the needs of patients in the population and to address identified care gaps. Recognizes profiles for physicians and patients ranging from limited intervention to complex needs. Focuses on coaching and coordination of care for identified patients and works alongside physicians, advanced care providers and office staff, focusing on identifying the needs of high risk and clinically complex patients, while assisting the practices in developing processes for managing patient populations. Promotes patient-centric care and actively participates in multidisciplinary patient-centered team meetings.

Requirements

Bachelor's Degree in Nursing.
Valid Registered Nurse license New Jersey and Pennsylvania.
Five years clinical experience in acute care, rehabilitation, sub acute, home care, managed health plan, or outpatient setting.
Utilization review and/or discharge planning experience preferred.
AHA BLS - Healthcare Provider
Registered Nurse - NJ
Registered Nurse - PA
Familiarity with community resources and social service resources
strong PC skills with experience navigating multiple electronic documentation systems
data analysis skills
highly developed interpersonal skills, including motivational interviewing.
Is innovative in how to approach the population and able to work with leadership to design and implement programs.
Requires travel to various practices on a routine basis.
Demonstrated ability to influence others while motivating them to change
multitasking and prioritization while working in a high-volume environment
working independently, as well as with teams

Nice To Haves

Utilization review and/or discharge planning experience
Case Management, Ambulatory Care, Care Coordination, or other relevant certification preferred.
Must complete an identified care coordination education program within six months of hire.

Responsibilities

Ensures identified patient care is coordinated with primary care, specialty care and outside agencies (ie. home care, rehabilitation, community resources etc).
Monitors transition of care phone calls and visits for patients following hospital admissions and emergency room visits. Monitors that appropriate services are in place and are being delivered as directed by the care team.
Conducts follow-up to ensure that initial patient assessment and post-visit consultation includes a comprehensive medical, psychosocial and functional assessment of the patients identified for tracking and monitors identified care team patients to ensure adherence to the plan of care, screenings, and treatment goals (including self-management goals).
Utilizes EMR/registries to prioritize patient follow-up, tracks follow-up visits with appropriate specialists, and tracks and reviews completeness of testing for identified complex patients (to includes chronic and acute measures).
Coaches and communicates with identified patients to ensure they are aware of instructions, has necessary prescriptions, access to medications and services, and what to look for regarding adverse events as per their care givers instructions.
Works with care teams to identify high-risk, high-need patients by helping to implement best practice processes for preventative services, chronic care and disease management.
Uses screening tools to select and track performance of identified patients, metrics and clinical outcomes.
Performs audits on identified performance and quality metrics.
Attends required training and collaboration sessions as scheduled.
Performs other duties as assigned.