Population Health Care Coordinator

Greater Baden Medical Services, Inc.•Brandywine, MD

2d•$25 - $30

About The Position

Greater Baden Medical Services (GBMS), a Federally Qualified Health Center serving Southern Maryland, is hiring a Population Health Care Coordinator to re-engage historically disengaged, non-compliant, and hard-to-reach patients attributed to the organization through Managed Care Organization (MCO) rosters. Using data registries provided by the Population Health Manager, the coordinator carries out targeted outreach campaigns, helps close HEDIS care gaps, arranges clinic appointments, and addresses initial barriers to care. The position also participates in community outreach events with the Population Health team. The coordinator works with high-volume monthly Medicaid and Medicare attribution rosters, conducting persistent digital and telephone outreach to patients with no healthcare footprint in the preceding 12–24 months. The role involves screening for barriers to care, providing basic insurance and benefit navigation, executing campaigns tied to quality improvement priorities, booking and preparing patients for appointments, and following up on hospital admissions and emergency department discharges. Patient contacts and outcomes are documented in the electronic health record, with complex cases and social needs referred to appropriate internal teams. The position also performs support and clerical duties, participates in team and MCO meetings and applicable workshops, and must be able to drive between GBMS locations. It operates in a professional office environment and routinely uses standard office equipment.

Requirements

High school diploma, GED, or equivalent certification of competency.
Previous experience scheduling appointments in a medical office setting.
Familiarity with basic medical terminology.
Ability to read and interpret written or verbal documents and instructions.
Ability to communicate effectively with patients, employees, and organizational stakeholders.
Ability to drive between Greater Baden Medical Services locations.
Ability to remain stationary for 50% of the time.
Ability to cope with stress, manage frequent interruptions and changing tasks, and adjust priorities as circumstances dictate.
Ability to communicate accurately, interact appropriately with colleagues, and analyze and synthesize information from multiple sources.

Nice To Haves

Certificate of completion from an accredited Medical Assisting Program.

Responsibilities

Scrub and work monthly Medicaid and Medicare MCO patient attribution rosters to locate and contact patients with no healthcare footprint over the past 12–24 months.
Conduct persistent, multi-channel outreach using high-volume calling, secure texting, and digital portal messaging to reintroduce GBMS medical, dental, and behavioral health services.
Screen patients by phone to identify barriers to care, including loss of insurance coverage, communication barriers, scheduling concerns, or mistrust of clinical environments.
Provide basic telephone insurance and benefit navigation and connect patients with internal financial counselors or eligibility specialists as needed.
Execute targeted telephone campaigns aligned with quality improvement cycles and HEDIS measures, including immunizations and diabetes and cancer screenings.
Use the EHR to book, reschedule, or change appointments and make warm transfers to clinical teams or scheduling staff.
Provide pre-appointment instructions, including arrival times, sliding fee scale documentation requirements, and clinical prerequisites.
Follow up by phone on CRISP alerts for hospital admissions and emergency department discharges, coordinating with the nursing team to arrange timely appointments.
Document patient interactions, refusal reasons, disconnected numbers, and bookings in the electronic health record.
Coordinate hand-offs to Population Health Nurses for complex clinical cases and to on-site Community Health Workers for patients needing immediate in-clinic social determinant interventions.
Participate in community outreach events with the Population Health team to engage the community, register disengaged patients, and promote primary care services.
Assist with scanning and filing medical test results and other documents in the medical record.
Retrieve voicemails, take patient messages, enter them in the EMR, and route them appropriately.
Perform clerical duties such as filing, photocopying, and collating.
Attend team and staff meetings, monthly MCO meetings, in-service meetings, and applicable workshops.
Perform other duties as assigned by the supervisor.