Population Health Patient Coordinator

Atrium Health Wake Forest Baptist; Winston-Salem (NC); On-site; USD 25,000 - 33,000; Full time

Job summary

Atrium Health Wake Forest Baptist is seeking a Community Health Worker to support patients and community members in navigating the healthcare system. You will educate on healthy behaviors, connect clients to resources, and collaborate with medical teams to coordinate care in diverse settings.

You will conduct home visits and community events, assess needs, maintain confidentiality, and help individuals develop healthier lifestyles while addressing social drivers of health.

Qualifications

• Completion of required certifications or continuing education in community health within the first year of employment.
• Experience working with diverse populations.
• Ability to engage medical providers, primary care teams, community-based organizations, referral navigators and social services agencies.
• Must have valid driver's license with reliable transportation.
• Flexibility to work evenings and weekends as needed.
• Knowledge of social determinants of health and health literacy principles.

Responsibilities

• Provide health education and prevention programs.
• Collect and maintain client records with confidentiality.
• Serve as liaison between clients and healthcare providers.
• Follow up with clients to ensure needs are met.
• Conduct home visits and community events.
• Educate on self-management of conditions and appropriate ER use.
• Assist with understanding care plans and instructions.
• Facilitate access to housing, food, clothing, prenatal classes, parenting, and mental health resources.
• Perform other duties as assigned.

Skills

Resource navigation

Interpersonal communication

Time management

Adaptability

Health literacy

Education

High School Diploma or GED

Tools

Epic EMR navigation

Job description

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

This job description indicates the general nature and level of work expected of the incumbent. It is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities required of the incumbent. Incumbent may be required to perform other related duties.