Population Health Clinical Care Coordinator
Southern Illinois HealthcareAbout the role
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Location: Remote
Shift: Days
Time Type: Full Time
Licenses and Certification
• Certified Medical Assistant or Certified Nursing Assistant Required
Education
• Two years college in medical or human services
Experience and Skills
Technical: One year experience as a CMA/CNA and effective user of an
Electronic Medical Record system, EPIC preferred.
Principal Accountabilities
• Standards of Performance: Respect, Integrity, Compassion, Collaboration,
Stewardship, Accountability, Quality
Working Conditions
• Remote work arrangement available
Physical Activities
• Intermittent hand manipulation required.
• Intermittent lifting and carrying of 20 lbs.
Role Specific Responsibilities
o Awareness of multiple chronic conditions and ability to coach patients
through the continuum of care using stated treatment or care plan with
ongoing outreach for optimal outcomes.
o Assists with care coordination efforts for patients recently released from
identified levels of care to ambulatory setting.
o Coach discharged patients to monitor comprehension and
understanding of treatment plan and goals for improvement post
discharge. Follow-up with patients according to risks for readmission
as needed within 30-days of discharge.
o Assists patients with medication adherence and coach patients of the
importance of compliance.
o Reports data as requested.
o Works under the supervision of Population Health Manager, Clinical
Director of Population Health and/or indirectly the Population Health
Medical Director.
o Conducts concurrent medical record review using specific indicators and
criteria selected for care gap reporting.
o Communicates with the clinicians as needed to coordinate care.
o Screens for social barriers to health and provides resources as needed.
o Develops and reports on hospitalization and other quality metrics
including identification of problem areas and plans for
improvement.
o Assists with orders for laboratory and diagnostic testing as appropriate per
department clinical guidelines.
o Participates in department huddles, meetings and other meetings as
appropriate
Compensation (Commensurate with experience):
$17.23 - $25.85To access our Benefits Guide/Plan Information, please click the link below:
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