Care Coordination & Population Health Specialist

Valley Health Systems, Inc.; Hurricane (WV); On-site; USD 42,000 - 64,000; Full time

Job summary

Valley Health Systems, Inc. is seeking a Care Management Specialist to collaborate with physicians, patients, and care teams to guide patients toward better health outcomes.

The role emphasizes reducing hospitalizations and emergent visits, with responsibilities including identifying high-risk patients, developing and following up on care plans, and ensuring HIPAA compliance in the EHR documentation.

Qualifications

• National medical assistant certification or appropriate state LPN or RN licensure.
• 2–5 years of clinical experience preferred.
• Experience in triage.
• Excellent observation, verbal and written communication skills.
• Excellent organizational skills with a strong attention to detail.
• Ability to work independently and multitask.
• Superior customer service skills with the desire to work with the public.
• Experience/proficiency with EPIC EHR preferred.

Responsibilities

• Proactively identify and enroll high risk patients with chronic illnesses.
• Assess patient needs.
• Establish care plan, triage needs, and refer to care team members as appropriate.
• Utilize the care plan to guide follow up and ongoing engagement.
• Review patient progress and assess for graduation.
• Assist in the development and achievement of health goals as directed by the primary care provider.
• Collaborate with physicians, patient and other health care providers to guide patients to better health outcomes in an effort to reduce unnecessary hospitalizations and emergent care visits.
• Document all communication and coordination of patient contact in the electronic health record (EHR).
• Proactively address needs of the patients and families through the concept of population management.
• Effectively communicates with all patients with specific attention to the vulnerable patient population.
• Provide self-management support in the form of patient coaching and motivational interviewing when appropriate.
• Acknowledges the importance of a team approach when providing patient care.
• Communicates and coordinates effectively when providing patient care.
• Actively participates in the medical home care team which is comprised of clinical and non-clinical working together towards a common goal: delivering quality care to our patients.
• Maintain compliance with all HIPAA and privacy standards
• Maintain compliance with all company policies and procedures
• Other duties as assigned.

Skills

Communication skills

Patient coaching

Organization

Multitasking

Customer service

Education

National medical assistant certification or appropriate state LPN or RN licensure

Tools

EPIC EHR

Job description

Valley Health Systems, Inc. is seeking a Care Management Specialist to collaborate with physicians, patients, and care teams to guide patients toward better health outcomes.

The role emphasizes reducing hospitalizations and emergent visits, with responsibilities including identifying high-risk patients, developing and following up on care plans, and ensuring HIPAA compliance in the EHR documentation.