Population Health Coach & Care Coordinator

Valley Health Systems, Inc.; Huntington (WV); On-site; USD 42,000 - 65,000; Full time

Job summary

Valley Health Systems, Inc. is seeking a care coordinator to assist health center staff in promoting patient health through education, case management and population health management using patient registries.

You will perform health coaching, coordinate care with providers and community partners, collect data for NCQA accreditation, and support disease management to improve long-term outcomes. The role emphasizes outreach for health and wellness and requires strong communication and

Qualifications

• High School Diploma or Equivalent; degree in Medical Assisting or Nursing preferred.
• Working knowledge of Medicaid/Medicare, adult learning and behavior change principles, chronic illnesses, co-morbidities and community based resources.
• Excellent verbal and written communication skills, telephonic interviewing skills, computer skills, and prioritization and organizational skills.

Responsibilities

• Provide health-coaching and consultation services to patients, within state licensure scope of practice requirements. Conducts health risk assessments, introduces case management services, identifies and addresses barriers to treatment adherence and educates members about healthy lifestyle choices within state licensure of practice requirements
• Collaborates with patients to establish goals and provides ongoing support to members such that they strive to make and sustain healthy lifestyle choices. Provides participants with educational materials.
• Collaborates with primary care health center staff and provider as well as medical home and other healthcare professionals to obtain specific and current health information in regards to member’s plan of care.
• Reviews data from variety of sources to assist in identifying co-morbid conditions, hospitalizations, prescriptions and other factors that could impact the health of the patient. Uses data to identify problems, set goals, plan interventions, and determine overall health status within the scope of practice.
• Assists in care coordination which may include obtaining test and referral results and communication with various entities including but not limited to community organizations, health plans, health facilities and specialists.
• Proactively address patient needs through population health management.
• Creates and manages patient registries that include care considerations for chronic disease management and preventive care.
• Effectively communicates with all patients with specific attention to the vulnerable patient population.
• Document all activities as outlined in the Valley Health Policy Manual
• Assist the operations team in collecting clinical data for NCQA accreditation, meaningful use, and insurance sponsored PCMH projects.
• Other duties as assigned.

Skills

Verbal and written communication

Telephonic interviewing

Computer skills

Prioritization and organization

Medicaid/Medicare knowledge

Education

High School Diploma or equivalent

Medical Assisting degree

Nursing degree

Tools

Electronic Health Records

Job description

Valley Health Systems, Inc. is seeking a care coordinator to assist health center staff in promoting patient health through education, case management and population health management using patient registries.

You will perform health coaching, coordinate care with providers and community partners, collect data for NCQA accreditation, and support disease management to improve long-term outcomes. The role emphasizes outreach for health and wellness and requires strong communication and