The Population Health Care Coordinator will support the primary and specialty care physicians in population health management by focusing care coordination attention on the high to moderate risk, chronic condition population by driving utilization and costs to improve efficiency, quality, cost of health care services on behalf of its patient population. The person in this role will be expected to collaborate with patients to facilitate healthy behaviors. Utilizes coaching to foster healthy diet, exercise, medication and disease management. Helps patients to learn strategies and skills designed to stabilize symptoms and prevent disease progression. Works closely with the healthcare provider and team to deliver ongoing patient support and reinforce the care plan.

Responsibilities

Skills Required: • Embody essential leadership skills and ability to influence others is a positive way • Possess organizational behavior skills with a focus on driving for results • Use effective interpersonal communication skills in order to successfully collaborate with physicians and engage patients and their families • Ability to produce well-organized and informative evaluations, reports and presentations • Work cooperatively and collaboratively with others • Work as part of a team and support team decisions • Adapt to changes in requirements/priorities for daily and specialized tasks • Understand data analysis and ability to interpret/summarize • Engage with diverse communities or vulnerable populations • Communicate effectively, both verbally and in writing • Be proficient in Microsoft Office Suite applications • Have strong relationship building and interpersonal skills • Ability to think critically and make informed decisions Responsibilities • Engages physician and practice team in proactive patient management by addressing medical and behavioral health care needs, follow-up, and referrals. • Utilizes high risk registry, Hospital census reports and other reports to identify and do outreach to targeted population benefiting from care management program. • Offers and coordinates care consultation to complex patient/caregiver in the practice setting or home as necessary to reinforce disease management education utilizing teach back methods or assist with completion of health care proxy, advanced care planning, or community resource navigation. • Contributes to comprehensive care plans in collaboration with physician and health care team based on evidence-based best practices for chronic illness care. • Participates in developing patient-centered care plans that address problems /barriers/goals and executes action plans relevant to obstacles in chronic condition management. • Provides referrals to appropriate community resources and support programs and ensures that patients can access and follow through on these referrals. • Assist in the development of departmental strategic plans and documentation policies and procedures, and integrated clinical and financial projects and systems. • Facilitate multi-disciplinary collaboration in designing, developing, and deploying quality payment program initiatives. • Ensures assessment and comprehensive care plans are completed/signed by provider within required time frame in compliance with Vandalia Health Network standards. • Adheres to all Vandalia Health Network policy and partner requirements. • Through revenue cycle and information technology projects and collaboration, provides support to improve efficiency and quality of workflow; complies with processes that encompass documentation and billing charges with respect to population health initiatives. • Collaborate with quality to improve metrics related to quality payment programs and incentive-based quality initiatives. • Documents current workflow processes to establish knowledge baselines and recommends improvements as needed. Serves as a central resource for the physicians and practice team as navigator, coach, and disease manager for the targeted patient population. • Analyzes retrospective/concurrent utilization and cost data and seizes opportunity to reduce gaps in care by making recommendations for efficiency, quality and cost improvement. • Understands organizational goals and accountability towards maximizing organization performance. • Be a subject-matter expert with respect to population health initiatives and serve as resource for all providers and staff • Engage and educate providers and teams on newest trends and optimal work patterns to increase quality metrics and provider time utilization. • Serve as provider-liaison for staff meetings throughout the organization with respect to quality payment programs and ACO participation. • Reviews high cost patients with physician and/or primary care team to understand drivers of cost, current treatment plan, future course and prognosis. • Ensure advance directives and appropriate referrals are addressed such as palliative/hospice and makes recommendations for cost reduction alternatives whenever appropriate • Support new team members and network participants in training and onboarding • Perform other related duties as assigned.

Knowledge, Skills & Abilities

Patient Group Knowledge (Only applies to positions with direct patient contact) The employee must possess/obtain (by the end of the orientation period) and demonstrate the knowledge and skills necessary to provide developmentally appropriate assessment, treatment or care as defined by the department’s identified patient ages. Specifically the employee must be able to demonstrate competency in: 1) ability to obtain and interpret information in terms of patient needs; 2) knowledge of growth and development; and 3) understanding of the range of treatment needed by the patients. Competency Statement Must demonstrate competency through an initial orientation and ongoing competency validation to independently perform tasks and additional duties as specified in the job description and the unit/department specific competency checklist. Common Duties and Responsibilities (Essential duties common to all positions) 1. Maintain and document all applicable required education. 2. Demonstrate positive customer service and co-worker relations. 3. Comply with the company's attendance policy. 4. Participate in the continuous, quality improvement activities of the department and institution. 5. Perform work in a cost effective manner. 6. Perform work in accordance with all departmental pay practices and scheduling policies, including but not limited to, overtime, various shift work, and on-call situations. 7. Perform work in alignment with the overall mission and strategic plan of the organization. 8. Follow organizational and departmental policies and procedures, as applicable. 9. Perform related duties as assigned.

Education

• Associate's Degree (Required) Education: Graduate of an accredited program for nursing (Licensed Practical Nurse Program or Associate or Bachelor's program in nursing is acceptable. Experience: Three (3) years of relevant care management preferred with experience and knowledge of: • Population health programs including annual wellness visits, chronic care management (and similar programs), Accountable Care Organizations (“ACO”), Medicare Shared Savings Programs, and Quality Payment Programs/Value Based Agreements from various other third-party payers • Prior experience in public health or other community nurse setting

Credentials

• Registered Nurse (Required)

Work Schedule: Days

Status: Full Time Regular

Location: Northgate-400 Association Dr.

Location of Job: US:WV:Charleston

Talent Acquisition Specialist: Lauren R. Lane lauren.lane@vandaliahealth.org