JOB PURPOSE - Reporting to the Director of Population Health, the Population Health Care Coordinator provides expertise to program participants by coordinating services and activities to improve patient health.
GENERAL DUTIES & RESPONSIBILITIES -
The Care Coordinator is responsible for recruiting participants who are at risk for developing pre-diabetes identified from partnering clinics, making quarterly home visits, identifying providers of services or family-based resources, encouraging utilization of age appropriate preventative medical care and attendance at scheduled medical visits, monitoring clinical and intervention services authorized for patient care, and conducting program specific education classes to promote healthier lifestyles among program participants.
The goal of population health management (PHM) is to keep a patient population as healthy as possible with the goal of preventing diabetes among the care coordinator's caseload (75 participants).
MINIMUM QUALIFICATIONS - Minimum qualifications include Masters preferred, BA or BS degree in biology, chemistry, nursing, public health or similar area, minimum of 3 years of related experience, computer proficiency, including Microsoft Office and a basic knowledge of clinical information systems. Must be self-disciplined, a team player, highly organized and have well-developed oral and written communication skills.
SPECIFIC DUTIES -
Recruit program participants and complete quarterly home visits for caseload.
Assist all program participants by acting as a patient advocate and navigator.
Facilitate health and disease patient education, lead healthy living education and exercise classes
Use electronic medical records (EMRs) and patient registry tools to track patient health care status; analyzes and updates disease registries
Assess patient health needs; identify patients who would benefit from specific health interventions, solicit and monitor patient participation, and coordinate continued patient care.
Perform other duties as assigned.
Delta Health Alliance