Care Coordinator - Connected Care

Description

POSITION TITLE: Population Health Specialist-- Connected Care

RESPONSIBLE TO: Chief Quality Officer

FLSA STATUS: Non-Exempt

Purpose of Position: The Care Coordinator - Connected Care supports the Quality Department in improving health outcomes for older adult patients through proactive outreach, care coordination, patient education, and connection to community resources. This position combines population health strategies with direct patient engagement to address barriers to care, improve care coordination, and support healthy aging. The Care Coordinator - Connected Care works closely with patients, caregivers, providers, and interdisciplinary care teams to identify patient needs, facilitate access to services, complete grant-required assessments and interventions, and support Valley Family Health Care's quality, value-based care, and population health goals. 

Requirements

QUALIFICATIONS:

1. High school diploma or equivalent required; post-secondary education in healthcare, public health, social services, or a related field preferred.
2. Minimum 2-5 years’ experience in healthcare, public health, care coordination, population health, or social services preferred.
3. Community Health Worker Certification or ability to obtain certification within 6 months.
4. Knowledge of healthcare systems, Medicare, Medicaid, community resources, and social determinants of health.
5. Excellent organizational skills and strong written and verbal communication skills.
6. Strong computer skills, particularly in Microsoft Excel and electronic health records.
7. Excellent customer service skills and an empathetic, culturally sensitive approach to working with diverse populations.
8. Valid driver’s license, insured vehicle, and ability to travel within the community.
9. Spanish fluency and/or bicultural experience is desirable.

RESPONSIBILITIES:

1. Support quality improvement initiatives, population health strategies, data collection, patient tracking, and reporting.
2. Utilize registries, electronic reports, and electronic health record tools to identify targeted patient populations, care opportunities, and barriers to care.
3. Review care gap reports and coordinate with patients, payors, clinical care teams, and community partners to close identified gaps.
4. Complete Connected Care assessments and protocols through clinic, telephone, community, and home-based encounters.
5. Assess patients’ health and social needs using Connected Care tools and address the 4Ms of an Age-Friendly Health System: What Matters, Medication, Mentation, and Mobility.
6. Collaborate with healthcare professionals to support care plans and facilitate referrals for medical, behavioral health, social, and supportive services.
7. Provide culturally responsive education and information to patients, families, and caregivers related to healthy aging, preventive care, and available resources.
8. Assist patients with Advance Directives, resource applications, and navigation of healthcare and community services as appropriate.
9. Maintain timely and accurate documentation of patient interactions, services, interventions, referrals, and outcomes in the electronic health record.
10. Complete and submit required Connected Care evaluation forms, grant documentation, and program reports within established timelines.
11. Maintain population health systems and tracking tools to support clean, accurate, and valid data.
12. Participate in program evaluation surveys, meetings, trainings, regional networks, and quality improvement activities.
13. Develop and maintain relationships with community organizations and service providers that support older adults.
14. Promote clear communication among the integrated care team and participate in VFHC meetings and committees as assigned.
15. Assist with meeting quality measures and value-based care goals by completing tasks related to VFHC initiatives.
16. Perform other duties as assigned.

Physical Requirements:

• Must be able to lift 25 lbs.
• Continuous sitting, utilizing a computer, and making phone calls.
• Ability to travel and meet with patients and families in clinic, home, and community settings.
• Correctable vision and hearing.
• The ability to communicate information and ideas so others will understand and exchange accurate information in these situations.
• The ideal candidate must be able to complete all physical requirements of the job with or without reasonable accommodation.