Care Coordinator for Population Health

Patient & Workplace Safety:

• Employee has knowledge and understanding of patient and workforce safety as it relates to job duties.

Patient Population:

• Demonstrates competency in the delivery of care and applies the knowledge to meet age-specific needs if applicable.

Principal Duties and Responsibilities:
* Assist in the design and implementation of population health management reports for gaps in care monitoring.
* Generate patient reports from the organization's electronic health record system to identify gaps in care and target patient care coordination outreach efforts.
* Review and monitor open care gaps from the targeted EMR chart review and payer reports. Review practice based EMR to collect proof of care gaps closure. Capture and upload care gap documentation to the EMR.
* Work with various insurance carriers to identify gaps in care for patient panel and work collaboratively with the Ambulatory care teams to ensure seamless patient outreach.
* Review risk-stratified lists of patients across Medicare, Medicaid, and Commercial insurers to prioritization of patient needs for access to community supports and services.
* Perform outbound reminder telephone calls/Letters, My Chart Messages for targeted Quality Care Initiatives in an effort to increase scores related to measures based on care gap reports.
Promote utilization of timely preventative care and work with the care team to prevent unnecessary Emergency Department visits and Hospital Admissions through the following:
* Utilizing CRISP: Notification system for ED and hospital admissions.
* Communicating with local hospitals to get the medical discharge summaries.
* Collaborating with the RN Care Managers and Providers for medication reconciliation and Hospital Follow-up appointments.
* Working high-utilizer panel of patients with multiple ED/Hospital Admissions. Working with multi-disciplinary care team (RN Care Manager, Behavioral Health Consultant, PCP, etc) to come up with plan of care to reduce hospital visits.
Coverage of care coordination work in the ambulatory primary care practice setting will include, but not be limited to:
* Identifying Social Determinants of Health (SDOH) which include social, medical, financial, needs and barriers) and connecting patients and families with community supports and services.
* Executing standing orders for tests and preventative services.
* Managing transitions of care and referrals to specialists.
* Anticipating the needs of the patient panel, ensuring that the necessary documentation and pre-visit planning is completed or requested before patient visits.
* Handling urgent on-call patient needs after hours by provider on call
* Completing medical record reconciliations to ensure testing, medications, office visits are current
* Work with care teams as a resource on care coordination of assigned patients that include: pre-visit planning, workflow to ensure care completion prior to visit whenever possible, after visit summary review with patients whenever appropriate, patient engagement to involve the patients in activities to improve their health, and patient education.
* Work in collaboration with inpatient Care Management and Coordination teams to ensure warm handoffs are provided for patients coming to the ED, hospital or who have recently been discharged from the hospital.
* Utilize Quality Improvement plan for reporting and improvement strategies, (PDSA) and Lean Daily Management (LDM).
* Attend staff and committee meetings including office based PCMH meetings and care management meetings.