Population Health Patient Coordinator

Overview

Bilingual candidates are encouraged to apply

JOB SUMMARY:

The Patient Coordinator is an essential member of the healthcare team who will serve as a cultural liaison, health navigator, health and wellness promoter, and advocate.  Facilitate access to health and social services to improve the health outcomes of individuals and their communities by addressing social determinants of health in culturally competent ways. The Patient Coordinator is an extension of the ambulatory care clinics/care management team and provides longitudinal care for their patient panels. The Patient Coordinator works in close collaboration with the Ambulatory Care Navigators, Population Health Social Workers, Enhanced Care Nurses, and other members of the health care team to identify high-risk vulnerable patients who need care coordination and connection to community resources.

EDUCATION/EXPERIENCE:

High School Diploma or GED required

LICENSURE, CERTIFICATION, and/or REGISTRATION:

CPR within 30 days of hire

Completion of a Community Health Worker Training course within one year of hire

Obtain Community Health Worker Certification within one year of hire

ESSENTIAL FUNCTIONS: 

1. Identifies and utilizes cultural and community resources.  Establishes and maintains relationships with service providers. 
2. Collaborates with the care manager and other members of the interdisciplinary care team to assist with the development and fulfillment of a comprehensive care plan. Receives and manages referrals and task assignments from care managers and other team members for screening, coordination and monitoring of social needs (non-clinical components). 
3. Facilitates appropriate utilization of services and transitions in care by assisting with educating families, facilitating communication between patients and providers and maintaining frequent communication with patients and providers. 
4. Provides social care for a panel of patients attributed to our Advanced Medical Home practices.
5. Utilize targeted reports and screening tools to identify patients who will benefit from care coordination and connection with health and social resources. The frequency and intensity of care coordination will be determined by the patient’s needs. 
6. Engages individuals to maximize strengths to achieve health, social, and personal goals. Assists the family in identifying and prioritizing patient and family needs. Schedules and conducts home, school or community visits as necessary to support families. 
7. Builds relationships with respect to diversity, using active listening, casual counseling and encouragement.
8. Identifies the elements of healthy lifestyle behaviors and understands the importance of self-management.
9. Educates patients on self-management of health conditions and supports patients in developing healthier habits and proper use of the healthcare system.
10. Documents patient engagement in the EMR in an effective and timely manner to ensure team awareness and patient safety.
11. Facilitates access to community resources, including locating housing, food, clothing, prenatal classes, parenting, and providers to teach life skills, and relevant mental health services.
12. Works to reduce cultural and socio-economic barriers between community members and the healthcare system
13. Performs other related duties incidental to the work and as assigned.

SKILLS & QUALIFICATIONS:

Strong interpersonal skills.

Strong verbal and written communication skills.

Ability to work collaboratively with all disciplines

Access to reliable transportation

Proficiency in Microsoft Office software programs

Ability to prioritize when multiple demands exist

Demonstrates and practices skills necessary to carry out effective home visits 

WORK ENVIRONMENT:

Regulator contact with persons in a wide variety of crisis situations, and under significant emotional stress

May be exposed to infectious and contagious diseases

May be exposed to blood borne pathogens

Protective equipment as directed by medical personnel when visiting designated patients

Travel required