Population Health Patient Coordinator

Hugh Chatham Health; Winston-Salem (NC); On-site; USD 30,000 - 45,000; Full time

Job summary

Hugh Chatham Health, Inc. is seeking a Population Health Coordinator to support patients and community members in navigating the healthcare system.

This on-site, first-shift role focuses on health education, care coordination, and connecting individuals with resources to improve health outcomes. You will work with medical providers, community organizations, and social services to assess needs, conduct follow-up, maintain confidential records, and support culturally sensitive outreach.

Qualifications

• Knowledge of community resources and health services.
• Ability to assess client needs and provide interventions.
• Experience working with diverse populations.

Responsibilities

• Provides direct health education and prevention services.
• Maintains confidential client records.
• Acts as liaison between clients and healthcare providers.
• Conducts follow-ups to ensure needs are met.
• Performs home visits and community events.
• Educates on self-management of health conditions and appropriate ER use.

Skills

Community resources

Needs assessment

Diverse populations

Interpersonal skills

Communication skills

EMR knowledge

Driver's license

Education

High School Diploma or GED

Tools

Epic EMR

Job description

Department

12210 Wake Population Health - Population Health

Department

12210 Wake Population Health - Population Health

Status

Full time

Benefits Eligible

Yes

Hours Per Week

40

Schedule Details/Additional Information

• This is an on-site, first shift position: 0800-1700, M-F

Pay Range

$21.85 - $32.80

You will play an integral role within the healthcare team, serving as a primary resource to assist patients and community members in navigating the complexities of the healthcare system. This position provides education on healthy behaviors and collaborates with patients and community stakeholders to reduce health-related risk behaviors in culturally sensitive and accepted ways. You will acknowledge the significance of addressing social drivers of health when guiding, supporting, and empowering individuals to achieve healthier lifestyles. Under the direction of healthcare leadership, the incumbent works closely with medical providers, primary care teams, community-based organizations, and social service agencies to deliver care coordination and facilitate access to resources and support, thereby enhancing overall health and well-being through targeted education and coordinated care.

Major Responsibilities

• Provides direct services to clients, such as health education and prevention programs.
• Collects and maintains client records, ensuring confidentiality.
• Acts as a liaison between clients and healthcare providers.
• Conduct follow-ups with clients to ensure their needs are being met.
• Conducts effective home visits and/or community events.
• Educates community members on self-management of health conditions and supports patients in developing healthier habits and proper use of the emergency room and providing information for alternatives.
• Assist community members in understanding care plans and instructions.
• Facilitates access to community resources, including but not limited to locating housing, food, clothing, prenatal classes, parenting, and providers to teach life skills, and relevant mental health services.
• Performs other duties as assigned.

Licensure, Registration, And/or Certification Required

• Completion of any required certifications or continuing education in community health within the first year of employment.

Education Required

• High School Diploma or GED required

Experience Required

• 1 – 2 years

Knowledge, Skills & Abilities Required

• In-depth knowledge of community resources and health services.
• Ability to assess client needs and provide appropriate interventions.
• Experience working with diverse populations.
• Ability to engage medical providers, primary care teams, community-based organizations, referral navigators and social services agencies. Adaptability based on changing needs of the organization.
• Possesses knowledge of the community and population for related programs. Ability to work effectively with a wide range of constituencies in a diverse community and work as a strong team member.
• Must have strong interpersonal skills and good communication and literacy skills (in person, telephonically and written) and demonstrate the ability to develop rapport as an active member of the care management team.
• Valid driver’s license required, excellent driving record and have reliable transportation.
• Time will be spent tracking and contacting community members and community referral agencies, meeting face-to-face with clients in their home environment, hospital, clinic, school, etc. Frequent changes are expected daily; therefore, flexibility and adaptability are essential. Evening and weekend work may periodically be required.
• Self-directed with excellent time management and detail orientation.
• Adaptability based on changing needs of the organization.
• Knowledgeable of social drivers of health, community health, and health literacy principles.
• Ability to navigate Epic or another Electronic Medical Record (EMR).
• Ability to navigate social care networks and platforms.

Physical Requirements And Working Conditions

• This position requires travel, therefore, will be exposed to weather and road conditions.
• Operates all equipment necessary to perform the job.
• Work in a variety of environments; an office environment, a community member’s home environment and/or hospital/school/community agency or settings.
• Exposure to a medical setting and household conditions as well as communicable diseases could occur.
• There is occasional lifting of 10 – 20 pounds necessary to complete a task.

Preferred Job Requirements

• Bachelor’s degree preferred

Note: Eligibility for programs listed above may depend on your FTE or status (e.g., full-time, part-time, per diem, temporary, etc.); please ask a Recruiter for more information during an interview.

Our Commitment To You

Advocate Health offers a comprehensive suite of Total Rewards: benefits and well-being programs, competitive compensation, generous retirement offerings, programs that invest in your career development and so much more – so you can live fully at and away from work, including:

Compensation

• Base compensation listed within the listed pay range based on factors such as qualifications, skills, relevant experience, and/or training
• Premium pay such as shift, on call, and more based on a teammate's job
• Incentive pay for select positions
• Opportunity for annual increases based on performance

Benefits And More

• Paid Time Off programs
• Health and welfare benefits such as medical, dental, vision, life, and Short- and Long-Term Disability
• Flexible Spending Accounts for eligible health care and dependent care expenses
• Family benefits such as adoption assistance and paid parental leave
• Defined contribution retirement plans with employer match and other financial wellness programs
• Educational Assistance Program

Note: Eligibility for programs listed above may depend on your FTE or status (e.g., full-time, part-time, per diem, temporary, etc.); please ask a Recruiter for more information during an interview.

About Advocate Health

Advocate Health is the third-largest nonprofit, integrated health system in the United States, created from the combination of Advocate Aurora Health and Atrium Health. Providing care under the names Advocate Health Care in Illinois; Atrium Health in the Carolinas, Georgia and Alabama; and Aurora Health Care in Wisconsin, Advocate Health is a national leader in clinical innovation, health outcomes, consumer experience and value-based care. Headquartered in Charlotte, North Carolina, Advocate Health services nearly 6 million patients and is engaged in hundreds of clinical trials and research studies, with Wake Forest University School of Medicine serving as the academic core of the enterprise. It is nationally recognized for its expertise in cardiology, neurosciences, oncology, pediatrics and rehabilitation, as well as organ transplants, burn treatments and specialized musculoskeletal programs. Advocate Health employs 155,000 teammates across 69 hospitals and over 1,000 care locations, and offers one of the nation’s largest graduate medical education programs with over 2,000 residents and fellows across more than 200 programs. Committed to providing equitable care for all, Advocate Health provides more than $6 billion in annual community benefits.