Population Health Coordinator

Recover Together

261d • Remote

About The Position

At Groups, the Population Health Coordinator will play a key role in our organization by supporting the delivery of high-quality care to select high-acuity member populations, as well as members in select transitional periods of their recovery journey. Each population health coordinator will be assigned to one of the following areas of focus and specialization: Medical Focus, Mental Health Focus, and Social Care Focus. Within their area of focus, the Population Health Coordinator supports quality care-delivery and quality improvement via a mixture of: registry review and data management; internal and external interdisciplinary collaboration and care coordination; documentation review and preparation; and direct member-facing care (group and individual). This role will play a key part in pioneering innovative care delivery methods at Groups, with a strong foundation in the Collaborative Care Model. As a result, the person in this role must be flexible, confident in engaging with multiple disciplines across various regions, and comfortable navigating ambiguity. This position requires a passion for leading, supporting, and participating in pilot projects to drive continuous improvement in patient care.

Requirements

• Strong understanding of care coordination and case management.
• Knowledge of health care regulations and HIPAA compliance.
• Excellent communication skills with the ability to effectively manage communications across a large, dispersed team.
• Proficient in facilitating clear and efficient communication across telehealth, virtual platforms, telephone, and in-person care settings.
• Willingness to work both in and out of the office depending on need.
• Exceptional ability to maintain focus, prioritize tasks effectively, adapt to rapid organizational changes.
• Problem-solving and decision making abilities to navigate complete care situations.
• Capacity to build trust and rapport with diverse patient populations.
• Proficiency with multiple EMR's, Microsoft Office / Google Suite, and other computer-based documentation tools.
• Excellent organizational and documentation skills.
• Ability to analyze data and outcomes.
• Ability to use discretion and work independently under general supervision.
• Ability to understand and adhere to the Professional Code of Conduct.

Nice To Haves

• Bachelor's degree in Nursing preferred for Medical Focus.
• Current licensed clinical social worker for Mental Health Focus.
• Current social worker, certified peer, certified community health worker for Social Care Focus.

Responsibilities

• Maintain an accurate registry of members enrolled in dedicated special populations or other care pathways.
• Use the registry to assess progress, track outcomes, and prioritize daily tasks for yourself and other members of the care team.
• Facilitate registry reviews with other members of the care team (counselors, medical providers, consulting specialists, etc).
• Participate in caseload consultation and communicate resulting treatment recommendations to the care team.
• Use the registry to assess the quality of care for the relevant populations and to propose population-level quality improvement initiatives.
• Support the local care teams by performing and documenting internal and external care coordination tasks for the most complex members or scenarios within the area of focus.
• Assist in training staff on how to practice within the Collaborative Care Model (registry review, asynchronous consultations, concise presentations etc).
• Support the individual needs of members on an assigned member caseload via telephonic and SMS outreach, and individual telemedicine encounters.
• Perform screenings, structured assessments, brief therapeutic interventions, care coordination with community providers, and other tasks as assigned for select members.
• Provide member education about common co-occurring mental health, physical health, and substance abuse disorders and the available treatment options.
• In partnership with peer support and care navigation, provide transitional care support to select high acuity members as they begin their recovery journey at Groups.
• Facilitate and document treatment plan changes for members with the clinical and medical providers.
• Escalate any urgent/crisis situations to the appropriate clinical and/or medical leadership and support team members through necessary follow up and safety planning activities.
• Provide administrative, technical, and leadership support on pilot projects, as delegated by medical, clinical, and operational leaders.

What This Job Offers

• Job Type: Full-time
• Industry: Professional, Scientific, and Technical Services