Care Coordinator - Population Health (CCPH)
Full Time + Benefits/PTO
REPORTS TO: COO
AREAS OF RESPONSIBILTY:
This Care Coordinator is responsible for population health registries for MVHC’s patients. Population Health focuses on specific activities that improve the health outcomes within our communities. These health outcomes are tailored around preventative care and chronic disease management. Population Health can also be focused on a specific insurance payor, such as Medicare, Medicaid or private payor source. MVHC Quality team will direct which specific population and outcomes the Care Coordinator will focus upon. The Care Coordinator is responsible for the activities and tasks around the focus population. These tasks will include things such as tracking, recalling, documenting, auditing and reporting of specified measures on a specific assigned patient population.
Prefer personnel who has previous experience with case management, care coordination, or experience with MVHC health care system. The Care Coordinator must have good written and verbal communication skills as there is a great deal of telephone and/or electronic communication with patients. The Care Coordinator must have great attention to detail, be outgoing, professional and enjoy connecting with patients via the telephone and computer. The Care Coordinator will continually maintain a professional and caring attitude toward patients and must maintain confidentiality relating to MVHC’s personnel, patients, and information that could result in proprietary damage to MVHC. The position requires intense use of computer technology using the EHR, various registries and /or apps, as well as other software programs necessary. The Care Coordinator must also possess critical thinking, time management and organizational skills, as well as the ability to work both independently and collaboratively. The Care Coordinator must possess an automobile, current valid California or Oregon driver’s license and auto liability insurance.
REQUIREMENTS AFTER HIRE:
Maintain current CPR card.
Clean and appropriate attire.
DUTIES AND RESPONSIBILITIES:
Provide panel management by recalling and tracking of assigned patient population which could be related to both preventative care and chronic disease management. Examples of this may include Annual Wellness Visits (AWV), cancer screenings, immunization recall, diabetic tracking measures (labs and special exams), hypertensive tracking, monitoring patients on persistent medications (such as PT/INR recall, patients taking diuretics), etc.
Utilize computer systems to assist with population management.
Coordinate patient visits to ensure preventative screenings coincide with acute or chronic encounters, such as immunization recall may need piggybacked with an overdue well child visit.
Become a super-user of certain electronic system that will assist with job function, such as Medicaid dashboards, ACO app, HIE registries.
Attend and participate in committee meetings, provide supporting documents/reports when needed for those meetings.
Run reports and share data as it relates to provider, sites, programs when needed.
Monitor and report trends of improvement or decline on programs or measures.
Interface with different committees on process improvement needs.
Inform supervisor of backlog of work, or any difficulty with recalls or tracking.
Cooperate and perform any other task that is asked as a MVHC team member.
CUSTOMER CARE: A core value of Mountain Valleys Health Centers’ is our dedication to high-quality customer care. As a Community Health Center, our patients are our vitality; therefore, every patient will be treated accordingly.
At MVHC a customer is defined as but not limited to a patient, vendor, contractor, granting agency, community business, and employee. Customers will be treated with the utmost dignity and respect regardless of their socio-economic status, insurance type, job position, and/or race, etc. Discrimination is unacceptable and is grounds for immediate termination.
Every employee of MVHC will adhere to the Accountability Measures outlined either at the onset of employment or at the date of this signed job description. Should these expectations not be upheld, the employee understands that disciplinary action will be taken which could lead to immediate termination.
PHYSICAL REQUIREMENTS: Sitting, working on computer for extended periods of time, repetitive motion of hands, close eye work, listening, speaking in person or on the phone, reading, hand writing, and minimal lifting/carrying objects up to 30 lbs.