Bilingual Population Health Coordinator

High Country Community Health; Boone (NC); On-site; USD 42,000 - 65,000; Full time

Job summary

High Country Community Health in Boone, NC, seeks a Population Health Coordinator within the Quality Improvement department to organize patient data, identify unmet needs, and engage patients in their own care. You will collaborate with the Director of QI/RM and the CMO to align provider and patient needs.

The role focuses on outreach, education about screenings gaps, and scheduling follow-ups to close care gaps, improving care coordination and patient outcomes.

Qualifications

• Associates degree and 1-2 years of experience, or a combination of education and experience.
• Fluent in Spanish and English.
• Preferred: NCQA recognition program PCMH, patient engagement surveys and EMR based reporting.

Responsibilities

• Contacts our patients who have been identified as having unmet needs in their care.
• Empower and educate patients to have knowledge of screenings gaps.
• Encourages patients to schedule doctor visits to close these gaps with their PCP.
• Provides the information necessary to overcome concerns, fears and barriers that might be keeping the patient from closing their gaps in care.
• Makes appropriate appointments based on what gaps each patient needs closing based on QI reports.
• Follow appropriate scripts when calling patients about scheduling their appointment.
• Aid in the optimization of clinical workflows.
• Outreach in the community for patient engagement and community support.
• Look for possible grant opportunities that would assist the closing of gaps for our patient population and discuss with your supervisor how to obtain the grant funding.
• Other duties as assigned.

Skills

Verbal communication

Bilingual English/Spanish

Teamwork

Critical thinking

EMR / EHR software knowledge

Patient engagement

Adaptability

Problem solving

Interpersonal skills

Education

Associate's degree

Tools

EMR software

Job description

Description

Department: Quality Improvement

Immediate Supervisor Title: Director of Quality Improvement/ Risk Management (QI/RM)

This position is responsible for gathering and organizing patient data. The Population Health Coordinator works to identify patients unmet needs, engage patients in their own care, gather summary information for treatment interventions, and enhance ongoing communication between the patient and her/his care team. This position collaborates with the Director of QI/RM and Chief Medical Officer (CMO) to ensure provider and patient needs are met.

Essential Job Responsibilities

• Contacts our patients who have been identified as having unmet needs in their care.
• Empower and educate patients to have knowledge of screenings gaps.
• Encourages patients to schedule doctor visits to close these gaps with their PCP.
• Provides the information necessary to overcome concerns, fears and barriers that might be keeping the patient from closing their gaps in care.
• Makes appropriate appointments based on what gaps each patient needs closing based on QI reports.
• Follow appropriate scripts when calling patients about scheduling their appointment.
• Aid in the optimization of clinical workflows.
• Outreach in the community for patient engagement and community support.
• Look for possible grant opportunities that would assist the closing of gaps for our patient population and discuss with your supervisor how to obtain the grant funding.
• Other duties as assigned.

Requirements

• Travel Requirements: Some travel is required for community outreach events, HCCH site visits, etc.

Education/Experience

Required: Associates degree, 1-2 years of experience, or a combination of education and experience.

Fluent in Spanish and English.

Preferred: Experience with quality improvement programs, integration and informatics related to planning and population health management and involving: Knowledge of NCQA recognition program PCMH, patient engagement surveys and EMR based reporting. Skill in interacting and communicating with patients, physicians and case managers.

Knowledge/Skills/Abilities

• Knowledge of medical office/electronic health record software
• Excellent verbal communication skills
• Ability to be flexible and work with changing priorities in a fast-paced environment
• Requires excellent problem solving and critical thinking skills
• Must be able to interact with individuals of all cultures, education, and levels of authority
• Must be able to function as part of a team
• Basic medical terminology required

Job Factors

• Physical Requirements: Requires extended periods of sitting. Some lifting less than 25 pounds. Must be able to work within and on a computer system for extended periods of time.

About The Company

HCCH provides equal employment opportunities (EEO) to all employees and applicants for employment without regard to race, color, religion, sex, national origin, age, disability or genetics. In addition to federal law requirements, HCCH complies with applicable state and local laws governing nondiscrimination in employment in every location in which the company has facilities. This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation and training.

HCCH conducts background checks on all final candidates. Employment is contingent upon a clear background check or approval of the CEO