Hybrid POPULATION HEALTH CARE COORDINATOR chez Dothouse Health

Description

SUMMARY:

The Population Health Care Coordinator will play a key role in assisting patients with achieving improved health outcomes. Using population health management strategies, the coordinator will leverage patient registries and referrals to ensure patients receive necessary follow-up care, preventive screenings, and support for managing chronic conditions. Working within a team-based care model, the coordinator will collaborate closely with providers, nurses, medical assistants, and case managers to improve patient engagement, address barriers to care, and advance health equity.

Depending on assignment, coordinators may focus on one or more priority areas, such as general primary care support, chronic disease self-management, behavioral health coordination, or women’s health coordination.

This role offers excellent experience in direct patient care coordination and population health management, making it a strong opportunity for individuals in a gap period between undergraduate and graduate studies in public health, nursing, or medicine.

GENERAL DUTIES & RESPONSIBILITIES:

Patient Outreach & Care Coordination

• Use population health registries and EHR reports to identify patients due for preventive screenings, chronic disease management visits, and follow-up care.
• Conduct proactive outreach (phone, portal, mail, text) to schedule appointments, close care gaps, and support patient engagement.
• Serve as a patient advocate and navigator, assisting patients in understanding plan of care, addressing barriers, and connecting to appropriate care team members, including community resource specialists.

General Primary Care Support (as assigned)

• Conduct outreach and scheduling for cancer screenings (e.g., cervical, breast, colorectal, lung) based on evidence-based guidelines.
• Coordinate and schedule adult preventive visits, including annual physicals and Medicare Annual Wellness Visits, and other routine checkups.
• Support pediatric and adolescent care coordination, including scheduling well-child checks and adolescent visits.
• Coordinate childhood and adult immunization outreach, education, and follow-up.
• Assist in ongoing care coordination for patients with diabetes and hypertension, ensuring regular monitoring, labs, and      follow-up visits.

Chronic Disease Self-Management Support (as assigned)

• Distribute home monitoring devices (e.g., Bluetooth-enabled blood pressure monitors, continuous glucose monitors) to eligible      patients.
• Provide in-person training on device use, data interpretation, and self-monitoring best practices.
• Assist patients with enrolling in and using the patient portal for EHR integration of home monitoring data.
• Monitor device engagement and data submission; follow up with patients to address barriers and provide troubleshooting.
• Maintain accurate registries of participants and document all outreach, education, and follow-up in the EHR.
• Communicate home readings to providers and care teams to adjust care plans.

Behavioral Health Coordination (as assigned)

• Monitor and triage referrals from DHH providers and staff to behavioral health services.
• Coordinate with DHH behavioral health clinicians to determine appropriate initial levels of care.
• Identify timely care options by reviewing internal and external resources, considering insurance coverage, financial needs,      language capacity, and other patient-specific factors.
• Facilitate linkage to care by scheduling patients with internal providers or assisting with navigation of external services.
• Maintain up-to-date lists of external behavioral health providers, including insurance acceptance, payment options, service type,      availability, and language capacity.
• Assist with BH quality measures, such as scheduling follow-up visits for patients hospitalized or seen in the ED for behavioral health conditions, and monitoring patients needing regular symptom tracking.
• Coordinate chronic pain management follow-up, including ensuring patients adhere to scheduled medication refills, complete      required provider visits, and meet monitoring requirements per clinic policy.
• Support Office-Based Addiction Treatment (OBAT) scheduling, including nurse and provider follow-up appointments per program protocols.

Women’s Health Coordination (as assigned)

• Conduct outreach and follow-up navigation for abnormal breast and cervical cancer screenings, ensuring timely diagnostic evaluation and treatment initiation.
• Ensure timely prenatal intake and postpartum care visits, monitoring data related to pregnancy testing and deliveries, and      scheduling visits when appropriate.
• Facilitate contraceptive care follow-up, including timely follow-up for Depo Provera injections.
• Collaborate with women’s health providers, primary care teams, and community resources to support comprehensive reproductive and sexual health care.

Data & Quality Improvement

• Document all patient interactions, outreach, and coordination in the EHR according to established workflows.
• Track assigned quality metrics and contribute to performance improvement strategies.
• Participate in population health and primary care team meetings to review data, share updates, and coordinate patient care      strategies.
• Contribute to developing and refining workflows, tools, and processes to improve patient engagement and outcomes.

Other Duties

• Maintain patient confidentiality and comply with HIPAA and organizational policies.
• Perform other related duties as assigned.

Requirements

 Education:

• Bachelor’s degree in a health-related field preferred; two years of relevant healthcare or patient outreach/navigation experience may substitute for degree.

Experience and Competencies:

• Experience in patient care coordination, health education, or case management, preferably in a primary care, community health, or behavioral health setting.
• Strong interpersonal and communication skills, with the ability to engage diverse patient populations in a responsive manner.
• Proficiency in navigating and documenting in electronic health records (EHR), preferably EPIC.
• Comfortable with patient technology training, including use of patient portals and home monitoring devices.
• Excellent organizational skills, with the ability to manage multiple priorities and meet deadlines.
• Commitment to advancing health equity and addressing social determinants of health.
• Ability to work effectively within an interdisciplinary care team.
• Bilingual skills (especially Vietnamese, Spanish, Cape Verdean Creole/Portuguese, Haitian Creole) preferred.

Technical Skills:

• Proficiency with Microsoft Office (Outlook, Excel, Word, Teams).
• Ability to learn and adapt to new software and health technology tools quickly.