Community Health Coordinator

1. Analyze insurance portals and Allscripts to identify gaps in care of patients and effectively coordinate with the clinical team, scheduling team and patients resolve these gaps.

• Mine and extract data in various insurance databases and dashboards
• Maintain and revise attribution lists of patients to SMC providers
• Mine and extract data regarding gaps/completion in patient care
• Measure completion of HEDIS measures for various insurers
• Design, create, modify and present reports via data visualization in various designs (column, bar, pie chart)
• Work with the Accountable Care Organization in maintaining patient attribution, completing annual Medicare HEDIS measures and care gap closures
• Participate in payer quarterly quality meetings with the Medicaid Managed Care Organizations (MCO) and the ACO

2. Communicate effectively.

• Communicate and collaborate effectively with health team members.
• Identify and recognize abnormal symptoms/changes in patient condition. Appropriately, reports condition changes to medical provider.
• Complete proper patient reports after each contact with appropriate signature forms accurately completed and signed.
• Responsible for contacting participants that are eligible for the program for enrollment and provides necessary wellness coaching to reduce or eliminate high-risk behaviors.
• Encourages adoption of habits that are conducive to a higher quality of life.

3. Performs other duties as assigned.