The Population Health Care Coordinator will be responsible for contributing to the success of JCMG's Population Health programs, Including Transitional Care Management (TCM), Chronic Care Management (CCM), Accountable Care Organization (ACO) and Value Based Care (VBC) initiatives by managing patients with chronic illnesses to work towards a patient centered focus on improving and supporting self-care directives and goals.
Job Specific Competencies:
1. Develop, implement, and update patient centered plans of care to be utilized by the care team to help direct patient goals and actions to improve health.
2. Conduct patient support calls to determine patient needs and identify resources, education, and assistance that is necessary to facilitate optimal self-care management directives.
3. Work with patient and family members to initiate and maintain a collaborative care plan approach to reach desired goals.
4. Maintain patient records which reflect current healthcare needs and supportive goals.
5. Initiate TCM and CCM services as directed by providers.
6. Identify learning opportunities with patients/families and provide or coordinate individualized and comprehensive teaching-learning interactions related to patient centered healthcare improvement and management.
7. Act as a resource for patient engagement and support to help facilitate appropriate use of healthcare services.
8. Ensure patient and/or family members demonstrate knowledge of health status, treatments, coping mechanisms and interventions in relation to their illness management.
9. Conduct medication reconciliation with the patient and/or family member to ensure accurate medication administration is being performed. Assist the patient and/or family member in identifying home medications, appropriate timing of medications, and financial resources for medication assistance.
10. Identify gaps in care and guide/educate patient on the need to address preventative health maintenance measures to facilitate optimal health.
11. Educate providers and staff on TCM, CCM, ACO, and VBC services, goals, and directives.
12. Facilitate transitions of care from acute care settings to home and ensure all gaps in care are addressed including follow-up appointments, medication management, etc.

13. Utilize VBC programs to identify and document closure of care gaps.
13. Collaborates with Director of Population Health regarding implementation, delivery and organization of TCM, CCM, ACO. and VBC services.
JCMG Core Competencies:
1. Strives for continuous quality improvement.
2. Participates in educational experiences designed to maintain and/or improve professional competence.
3. Maintains high work ethic standards.
4. Provides quality customer service to staff, patients and visitors at all times.
Minimum Qualifications
Education:

• Associate or Bachelor’s degree in nursing

Experience:

• Preference to those with a minimum of one-year experience in case management in the healthcare setting

Certification/License:

• LPN or RN

Knowledge/Skills/Abilities:

• Strong communication skills, including the abilities to effectively communicate both verbally and in writing, internally and externally and at all levels of the organization
• Applied knowledge in patient centered healthcare prevention and management with emphasis on chronic illness management.
• Strong organization and interpersonal skills related to patient/provider communication and coordination.
• Must be able to demonstrate effective communication telephonically with proficient communication skills and assessment

Work Environment

• Works in heated and air-conditioned area; Occasionally, work may involve driving to satellite locations.