Population Health & Care Coordination Specialist

Louisville Metro Government; Kentucky; On-site; USD 42,000 - 64,000; Full time

Job summary

Louisville Metro Government seeks a patient liaison to bridge medical staff, patients and insurers to remove barriers to care and boost participation in primary health services.

The role identifies gaps, schedules follow‑ups, and supports care coordination within Family Health Centers across Louisville. Strong communication, organization, and data entry into the EHR are essential for successful care plans.

Qualifications

• Bachelor's Degree in Social Work, Public Health, or a closely related field.

Responsibilities

• Reviews patient care plan data provided by patients’ insurance companies.
• Schedules appointments for the patient with the patient’s provider, for annual screenings, or for other in‑house consultations for successful completion of the patient’s care plan.
• Participates in Quality Improvement (QI) activities.
• Connects patients who have not received primary care services for treatment or prevention to an appropriate FHC care team.
• Ensures that patient data is entered into FHC’s Electronic Health Record (EHR) system for follow up and accurate reporting.
• Provides outreach to patients by connecting them with their assigned medical provider so assigned annual screenings and treatment plans are completed.
• Counsels patients on recommended health screenings.
• Provides direction and education to FHC patients who are over‑utilizing emergency room visits, and coordinates appointments with their primary care provider(s) for more efficient care.
• Alerts medical providers of patient diagnoses that need to be addressed for risk adjustments and care gaps during medical visits.
• Communicates with FHC patients who were discharged from hospitals to coordinate follow‑up care.
• Communicates with all providers and members of the care team and documents care to minimize fragmented care.
• Adheres to standard precautions.
• Performs related work as required.

Education

Bachelor's Degree in Social Work, Public Health, or a closely related field

Job description

Louisville Metro Government seeks a patient liaison to bridge medical staff, patients and insurers to remove barriers to care and boost participation in primary health services.

The role identifies gaps, schedules follow‑ups, and supports care coordination within Family Health Centers across Louisville. Strong communication, organization, and data entry into the EHR are essential for successful care plans.