Promise Healthcare
Prenatal & Population Health Care Coordinator
Promise Healthcare, Champaign, Illinois, United States, 61820
Job Description
Job Description
At Promise Healthcare, our mission is to improve the health and well-being of the diverse communities we serve by providing high-quality, equitable healthcare to people of all ages. Our vision is to be a catalyst for positive change, shaping a future where healthcare is not a privilege but a fundamental right for every person and no one is left behind. Be a part of a team that values excellence, equity, and community. If you're ready to lead with passion and precision, apply now to become our Prenatal & Population Health Care Coordinator and help us make a lasting impact on the future of healthcare. The Prenatal & Population Health Care Coordinator coordinates prenatal services, provides billable Chronic Care Management (CCM), and supports Promise Healthcare's population health strategy. This position tracks confirmed pregnancies, monitors and encourages timely prenatal entry and healthy birth outcomes, closes care gaps across patient populations, and connects patients to medical, dental, behavioral, and community services. Responsibilities are structured to align with National Committee for Quality Assurance (NCQA) Population Health Management (PHM) standards, supporting both organizational quality goals and accreditation. ESSENTIAL DUTIES & RESPONSIBILITIES: Prenatal & Maternal Health Coordination : Identify and track all patients with confirmed pregnancies in NextGen electronic health record (EHR). Monitor and report prenatal program measures: UDS early entry into care and birth weight. Conduct proactive outreach to ensure timely prenatal visits and consistent follow-up. Provide education to patients and families on prenatal, postpartum, and well-woman care. Link patients to wraparound services (WIC, behavioral health, dental, community resources). Chronic Care & Case Management : Enroll and actively manage patients eligible for Chronic Care Management (CCM), ensuring accurate documentation for billable services. Conduct comprehensive assessments and develop individualized care plans for patients with chronic conditions or emerging risks. Support care transitions after hospitalizations or ER visits, coordinating timely follow-up. Provide patient coaching, education, and referrals to improve self-management and medication adherence. Collaborate with providers, referral coordinators, case management, and enrollment to address barriers (transportation, housing, food insecurity). Population Health & Quality Improvement : Participate in population assessment and risk stratification to identify high-risk and priority patient groups. Use EHR, payer databases, and community data to monitor outcomes and close care gaps. Support UDS, HEDIS, and Pay-for-Performance (P4P) initiatives by tracking screenings, preventive care, and chronic disease management. Apply quality improvement methods (SMART goals, PDSA cycles, root cause analysis) to refine workflows and improve outcomes. Document all patient interactions and outcomes in the EHR, ensuring data accuracy and integrity. Community & System Integration : Refer to integrated care to screen patients for social determinants of health (SDOH) and connect them to appropriate community programs (transportation, housing, etc.). Maintain updated knowledge of available community resources and support referral coordination and
enrollment/enabling
services. Foster partnerships with local organizations to expand available resources and reduce service gaps. Promote patient engagement and shared decision-making through education, patient portal support, and care planning. Advocate for patients to ensure equitable access to medical and supportive services. Other Responsibilities : Assist with patient engagement activities, such as portal enrollment and satisfaction surveys. Participate in staff meetings, training sessions, and interdisciplinary care team discussions. Support Promise Healthcare's mission, vision, and quality improvement plan. Perform other related duties as assigned. QUALIFICATIONS: Strong organizational skills, attention to detail, and ability to manage multiple priorities. Must deliver outstanding customer service and communicate with patients, colleagues, and other stakeholders with courtesy, professionalism, and respect. Ability to think critically, work independently, and collaborate across teams. Must exhibit cultural sensitivity and be accustomed to and comfortable with working in an inclusive environment and with a diverse patient population. Ability to foster collaborative relationships with clinical leaders and staff, payors, and external partners. Possess initiative, flexibility, and the ability to follow organizational protocols. Ability to adapt to changing work environment and duties as needed/assigned. EDUCATION / EXPERIENCE REQUIREMENTS: High School diploma or equivalent required; bachelor's degree in social work, public health, nursing, or related field preferred. Minimum one year of experience in a Federally Qualified Health Center (FQHC) or community health setting preferred. Prior experience in case management, quality improvement, or population health strongly preferred. Proficiency in NextGen EHR preferred.
AMAZING BENEFITS: Medical Dental Vision 401k with employer match FSA Vacation Sick Leave Proposed salary range: $38,000 to $54,000 We are an Equal Opportunity Employer and do not discriminate against any employee or applicant for employment because of race, color, sex, age, national origin, religion, sexual orientation, gender identity, status as a veteran, and basis of disability or any other federal, state or local protected class.
Completed background check and drug screen required prior to start date.
Job Description
At Promise Healthcare, our mission is to improve the health and well-being of the diverse communities we serve by providing high-quality, equitable healthcare to people of all ages. Our vision is to be a catalyst for positive change, shaping a future where healthcare is not a privilege but a fundamental right for every person and no one is left behind. Be a part of a team that values excellence, equity, and community. If you're ready to lead with passion and precision, apply now to become our Prenatal & Population Health Care Coordinator and help us make a lasting impact on the future of healthcare. The Prenatal & Population Health Care Coordinator coordinates prenatal services, provides billable Chronic Care Management (CCM), and supports Promise Healthcare's population health strategy. This position tracks confirmed pregnancies, monitors and encourages timely prenatal entry and healthy birth outcomes, closes care gaps across patient populations, and connects patients to medical, dental, behavioral, and community services. Responsibilities are structured to align with National Committee for Quality Assurance (NCQA) Population Health Management (PHM) standards, supporting both organizational quality goals and accreditation. ESSENTIAL DUTIES & RESPONSIBILITIES: Prenatal & Maternal Health Coordination : Identify and track all patients with confirmed pregnancies in NextGen electronic health record (EHR). Monitor and report prenatal program measures: UDS early entry into care and birth weight. Conduct proactive outreach to ensure timely prenatal visits and consistent follow-up. Provide education to patients and families on prenatal, postpartum, and well-woman care. Link patients to wraparound services (WIC, behavioral health, dental, community resources). Chronic Care & Case Management : Enroll and actively manage patients eligible for Chronic Care Management (CCM), ensuring accurate documentation for billable services. Conduct comprehensive assessments and develop individualized care plans for patients with chronic conditions or emerging risks. Support care transitions after hospitalizations or ER visits, coordinating timely follow-up. Provide patient coaching, education, and referrals to improve self-management and medication adherence. Collaborate with providers, referral coordinators, case management, and enrollment to address barriers (transportation, housing, food insecurity). Population Health & Quality Improvement : Participate in population assessment and risk stratification to identify high-risk and priority patient groups. Use EHR, payer databases, and community data to monitor outcomes and close care gaps. Support UDS, HEDIS, and Pay-for-Performance (P4P) initiatives by tracking screenings, preventive care, and chronic disease management. Apply quality improvement methods (SMART goals, PDSA cycles, root cause analysis) to refine workflows and improve outcomes. Document all patient interactions and outcomes in the EHR, ensuring data accuracy and integrity. Community & System Integration : Refer to integrated care to screen patients for social determinants of health (SDOH) and connect them to appropriate community programs (transportation, housing, etc.). Maintain updated knowledge of available community resources and support referral coordination and
enrollment/enabling
services. Foster partnerships with local organizations to expand available resources and reduce service gaps. Promote patient engagement and shared decision-making through education, patient portal support, and care planning. Advocate for patients to ensure equitable access to medical and supportive services. Other Responsibilities : Assist with patient engagement activities, such as portal enrollment and satisfaction surveys. Participate in staff meetings, training sessions, and interdisciplinary care team discussions. Support Promise Healthcare's mission, vision, and quality improvement plan. Perform other related duties as assigned. QUALIFICATIONS: Strong organizational skills, attention to detail, and ability to manage multiple priorities. Must deliver outstanding customer service and communicate with patients, colleagues, and other stakeholders with courtesy, professionalism, and respect. Ability to think critically, work independently, and collaborate across teams. Must exhibit cultural sensitivity and be accustomed to and comfortable with working in an inclusive environment and with a diverse patient population. Ability to foster collaborative relationships with clinical leaders and staff, payors, and external partners. Possess initiative, flexibility, and the ability to follow organizational protocols. Ability to adapt to changing work environment and duties as needed/assigned. EDUCATION / EXPERIENCE REQUIREMENTS: High School diploma or equivalent required; bachelor's degree in social work, public health, nursing, or related field preferred. Minimum one year of experience in a Federally Qualified Health Center (FQHC) or community health setting preferred. Prior experience in case management, quality improvement, or population health strongly preferred. Proficiency in NextGen EHR preferred.
AMAZING BENEFITS: Medical Dental Vision 401k with employer match FSA Vacation Sick Leave Proposed salary range: $38,000 to $54,000 We are an Equal Opportunity Employer and do not discriminate against any employee or applicant for employment because of race, color, sex, age, national origin, religion, sexual orientation, gender identity, status as a veteran, and basis of disability or any other federal, state or local protected class.
Completed background check and drug screen required prior to start date.