Coordinator Population Health (Hybrid - Troy, MI) - Populance

Are you seeking purpose by being part of a team committed to supporting doctors, hospitals and health plans to make sure patients get the right care at the right place and the right time? Consider this great opportunity to join Populance (powered by Henry Ford Health) - a company dedicated to advancing population health. This non-exempt daytime hours position will be a hybrid role, requiring a blend of remote work and in person for meetings and clinic visits as required. https://www.populance.org/

GENERAL SUMMARY:

The Population Health Coordinator is a member of the patient-centered care team responsible for collaborating with integrated case managers to provide support to patients and their families that optimize health outcomes. Interfaces with insurance companies, community agencies, clinical entities and specialized programs to support accurate communication and operational transactions.

PRINCIPLE DUTIES AND RESPONSIBILITIES:

• Provides outreach to patients identified as needing preventive care, assistance with addressing Social Determinant of Health (SDOH) barriers or assistance accessing the health system.
• Engages patients and their families as part of the care team to support ongoing communication, health education, identification of resources and service facilitation.
• Under the guidance of the integrated case manager provides coordination as necessary to ensure patients seamlessly and safely transition between care settings.
• In collaboration with other members of the care team, continually evaluates the patient's response to the care/treatment plan reporting changes when indicated.
• Provide systematic monitoring of Epic gap-in-care, attribution reports and Payor portal reports to identify and coordinate care for patients in need of tests, appointments and/or lab orders.
• According to clinic standing order protocols enters orders into Epic for routine preventive screening such as mammography.
• Performs other duties as assigned.