The Population Health Coordinator (PHC) is responsible for working with assigned beneficiaries/patients advocating health needs and assisting the care management team in coordinating the delivery of cost-effective health care services, and improve the outcomes for beneficiary/patients. Must utilize skills, including those of building positive relationships, and demonstrate effective written and verbal communication. The PHC must be knowledgeable of community resources and services to impact Social Determinants of Health. The PHC participates with the care management team in achieving Population Health Management objectives and goals related to programs, initiatives, and activities within care management at Franciscan Alliance. WHO WE ARE With 12 ministries and access points across Indiana and Illinois, Franciscan Health is one of the largest Catholic health care systems in the Midwest. Franciscan Health takes pride in hiring coworkers that provide compassionate, comprehensive care for our patients and the communities we serve. WHAT YOU CAN EXPECT Modify outreach frequency in order to effectively monitor self- management to prevent adverse outcomes. Utilizes motivational and health-coaching techniques to engage the beneficiary and support system. Assist with coordinating services with Care Manager's direction, as needed (e.g., durable medical equipment, Home Health, etc.) Reinforces education to the beneficiary/patient and/or support system. Identifies gaps in care and in collaboration with care management team and/or provider assists with facilitation of resources, if appropriate to meet specific patient needs. Provides or facilitates appropriate education, using a person and family-centered approach, to facilitate the achievement of health goals. Collaborate with health care team (e.g., physician, nurses, pharmacist, etc.) and elevates treatment plan questions/concerns and interventions for further discussion with health care team on SDoH factors impacting patient adherence and success in meeting their health care goals. Assists with identification of educational needs of beneficiary/patient, support system and health care team. Assesses patient's social determinants of health (SDoH) utilizing system-wide assessment tool in Epic. Communicating across care teams. Providing resource support to patient if needed. Monitor patient outreach and collaborate with care team related to remote patient monitoring (RPM) engagement and support.
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Job Type
Full-time
Career Level
Entry Level
Education Level
High school or GED
Number of Employees
5,001-10,000 employees