Population Health Patient Coordinator
About The Position
Make a meaningful impact in the lives of patients and communities by becoming a vital connector in the healthcare system. As a Population Health Patient Coordinator, you will serve as a cultural liaison, health navigator, wellness promoter, and dedicated advocate—helping individuals access the health and social resources they need to thrive. In this role, you will strengthen continuity of care across ambulatory clinics, build trusted relationships, address social determinants of health in culturally competent ways, and work alongside a dynamic interdisciplinary team to support high‑risk, vulnerable patients. If you’re passionate about equity, connection, and empowering others, this is an opportunity to create lasting change.
Requirements
- High School Diploma or GED (required)
- CPR certification within 30 days of hire (required)
- Completion of a Community Health Worker (CHW) Training course within one year of hire (required)
- Community Health Worker Certification within one year of hire (required)
Nice To Haves
- Bachelor’s degree in a relevant human services field (preferred)
Responsibilities
- Identify and utilize cultural and community resources; establish and maintain relationships with local service providers.
- Collaborate with care managers and interdisciplinary team members to support the development and execution of comprehensive care plans.
- Receive and manage referrals and assigned tasks for screening, coordination, and monitoring of social (non‑clinical) needs.
- Facilitate appropriate use of services and smooth care transitions by educating families, communicating between patients and providers, and maintaining regular contact with both.
- Provide social care support for a defined patient panel within Advanced Medical Home practices.
- Use targeted reports and screening tools to identify patients who would benefit from care coordination and connection to community resources; adjust frequency and intensity of support based on patient need.
- Engage individuals to build on strengths and work toward health, social, and personal goals.
- Assist families in identifying and prioritizing needs; schedule and conduct home, school, or community visits as needed.
- Build trusting relationships through respect for diversity, active listening, casual counseling, and encouragement.
- Identify elements of healthy lifestyle behaviors and reinforce the importance of self‑management.
- Educate patients on self‑management of health conditions and support the development of healthier habits and effective use of the healthcare system.
- Document all patient engagement, assessments, and follow‑up in the EMR accurately and promptly.
- Facilitate access to community resources such as housing, food, clothing, prenatal and parenting classes, life‑skills support, and mental health services.
- Work to reduce cultural and socioeconomic barriers between patients and the healthcare system.
- Perform other related duties as assigned to support patient and community health.
Benefits
- Advocate Health offers a comprehensive suite of Total Rewards: benefits and well-being programs, competitive compensation, generous retirement offerings, programs that invest in your career development and so much more – so you can live fully at and away from work, including:
- Compensation Base compensation listed within the listed pay range based on factors such as qualifications, skills, relevant experience, and/or training Premium pay such as shift, on call, and more based on a teammate's job Incentive pay for select positions Opportunity for annual increases based on performance
- Benefits and more Paid Time Off programs Health and welfare benefits such as medical, dental, vision, life, and Short- and Long-Term Disability Flexible Spending Accounts for eligible health care and dependent care expenses Family benefits such as adoption assistance and paid parental leave Defined contribution retirement plans with employer match and other financial wellness programs Educational Assistance Program
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What This Job Offers
Job Type
Full-time
Career Level
Entry Level
Education Level
High school or GED
Number of Employees
11-50 employees
