Population Health Care Coordinator - RN

POSITION SUMMARY:
The Population Health Care Coordinator works in collaboration and partnership within an interdisciplinary team to manage chronic healthcare conditions for patients with two or more chronic conditions and tangential issues. This role will focus on Patient Centered Medical Home (PCMH), quality improvement, comprehensive care management services, value based care, and closing care gaps. The Population Health Care Coordinator will ensure transparent whole person care and will support patient activation in care, improved population health outcomes and increased health literacy.

SALARY RANGE: $58,700-$66,120

• Promote timely access to appropriate and encompassing care in compliance with standards set forth through HRSA and NCQA
• Create and promote adherence to a care plan, developed in coordination with the patient, primary care provider and care team
• Cultivate and support primary care and specialty provider co-management with timely communication, inquiry, follow-up and integration of information into the care plan
• Increase continuity of care by supporting effective mechanisms in transitions of care and managing relationships with secondary and tertiary care providers and referrals
• Increase patients’ ability for self-management and shared decision-making
• Establish relationships with relevant community resources, resulting in the connection of patients to these resources with the goal of enhancing patient health and well-being, increasing patient satisfaction and reducing health care costs
• Assess patient health literacy and utilize effective strategies to increase understanding and activation in care
• Anticipate and meet or exceed all patient needs.
• Attend all Care Coordinator training courses/webinars and meetings
• Collect and analyze population health outcomes and Provide feedback for the improvement of the Care Coordination Program
• Assist in identifying appropriate QI initiatives to improve health outcomes for general Primary Care and Specialty Care
• Facilitate, implement and evaluate QI activities to improve chronic care management among care teams
• Increase efficiencies through the use of improved workflows and integration of service delivery to address complexity of chronic disease management.
• Will participate in ongoing professional and personal development related to enhanced leadership activities and evidence-based practices
• Other duties as assigned.

• Required: RN Licensed in Ohio
• Required: Associate’s Degree in any discipline

• Knowledge of clinical quality indicators for Ryan White, FQHC, Meaningful Use and PCMH
• 2-3 years of RN experience in a clinical setting
• Evidence of essential leadership, communication and counseling skills
• Highly organized with ability to keep accurate notes and records
• Experience with Quality Improvement and change management preferred
• Must have sensitivity to, interest in and competence in cultural differences, HIV/AIDS, minority health, and a demonstrated competence in working with persons of color, and LGBTQ communities.
• Proficiency in all Microsoft Office applications and other computer applications required. Experience with EPIC highly preferred and ability to learn new technologies, web tools, and basic design tools is imperative
• Knowledge of ambulatory care nursing principles or experience in an outpatient setting preferred
• Must have reliable transportation and valid Ohio driver’s license