Population Health Coordinator
Current• Risk stratify patient panels using EHR, plan data, manage and other relevant data for proactive intervention in order to stabilize or decrease their risk level.• Convert data to information and share with clinics. Provide clinic and provider level data to clinical team members and coordinate in-clinic patient care and services. Assist clinic team with preparing charts for gap closure.• Educate and counsel patients on health promotion with disease specific conditions that promote self-management of chronic disease and healthy lifestyle practices to reduce risk.• Use behavioral change strategies and interventions that include motivational interviewing, readiness to change, self-management education health belief model and adult learning theories.• Implement the quality initiatives and PDSAs to improve the quality of care and increase patient satisfaction.• Offer population health management support to patients based on screening and monitoring service needs and risk categorization including referrals based on care gaps and risk to internal or external services, community-based agencies.• Provide educational consultations to patients about team-based care, resource navigation, adherence to care and services.• Collect required data and information to complete monthly and annual reports; assist with creating report and data collection systems that work with the electronic medical records and manual record systems to meet agency and program reporting requirements.• Ensure a comprehensive health care delivery along a continuum, in-clinic, collaboration specialists, community health specialists and other community agencies. Engage in referral tracking and chart reviews of outside records.
