GBMC HealthCare
Care Coordinator for Population Health
GBMC HealthCare, Baltimore, Maryland, United States, 21276
Overview
Care Coordinator for Population Health role at GBMC HealthCare. The position focuses on ensuring compliance with the quality goals and metrics set by the health system and various insurance carriers, designing and implementing population health management reports related to monitoring gaps in care and care coordination activities. The role generates and reviews patient reports from the organization’s electronic health record system to identify gaps in care and target patient care coordination outreach. Primary responsibilities include promoting population health management and quality performance through data and reporting, overseeing coordination of care activities for patients in need, and linking patients to health care services, community resources, and social supports. The role works collaboratively with the Practice Manager, Lead Physician, RN Care Manager, Behavioral Health Consultant and other care team members within the ambulatory primary care setting, and may serve as a back-up to Care Coordinators embedded in the primary care, Patient Centered Medical Home setting.
Education
High School Graduate or higher
Experience
3 years Medical Office experience and experience navigating the healthcare system
Skills
Knowledge of medical and insurance terminology
Skill in oral and written communication to address inter- and intradepartmental concerns, solve problems and address conflict.
Skill in problem solving using available resources in innovative ways.
Customer service
Computer and personal productivity skills to enable effective use of EMR, e-mail, the internet, word processing, spreadsheets, presentation and database packages.
Analytical skills necessary to prepare and interpret reports
Navigating the health care system and providing resources to patients.
Demonstrate problem solving skills and the ability to research and evaluate innovative ways to use community resources
Patient & Workplace Safety
Employee has knowledge and understanding of patient and workforce safety as it relates to job duties.
Patient Population
Demonstrates competency in the delivery of care and applies the knowledge to meet age-specific needs if applicable.
Principal Duties and Responsibilities
Assist in the design and implementation of population health management reports for gaps in care monitoring.
Generate patient reports from the organization’s electronic health record system to identify gaps in care and target patient care coordination outreach efforts.
Review and monitor open care gaps from the targeted EMR chart review and payer reports. Review practice based EMR to collect proof of care gaps closure. Capture and upload care gap documentation to the EMR.
Work with various insurance carriers to identify gaps in care for patient panel and work collaboratively with the Ambulatory care teams to ensure seamless patient outreach.
Review risk-stratified lists of patients across Medicare, Medicaid, and Commercial insurers to prioritization of patient needs for access to community supports and services.
Perform outbound reminder telephone calls/Letters, My Chart Messages for targeted Quality Care Initiatives in an effort to increase scores related to measures based on care gap reports.
Promote Utilization Of Timely Preventative Care And Work With The Care Team To Prevent Unnecessary Emergency Department Visits And Hospital Admissions
Utilizing CRISP: Notification system for ED and hospital admissions.
Communicating with local hospitals to get the medical discharge summaries.
Collaborating with the RN Care Managers and Providers for medication reconciliation and Hospital Follow-up appointments.
Working high-utilizer panel of patients with multiple ED/Hospital Admissions. Working with multi-disciplinary care team (RN Care Manager, Behavioral Health Consultant, PCP, etc) to come up with plan of care to reduce hospital visits.
Coverage of care coordination work in the ambulatory primary care practice setting will include, but not be limited to:
Identifying Social Determinants of Health (SDOH) which include social, medical, financial, needs and barriers) and connecting patients and families with community supports and services.
Executing standing orders for tests and preventative services.
Managing transitions of care and referrals to specialists.
Anticipating the needs of the patient panel, ensuring that the necessary documentation and pre-visit planning is completed or requested before patient visits.
Handling urgent on-call patient needs after hours by provider on call
Completing medical record reconciliations to ensure testing, medications, office visits are current
Work with care teams as a resource on care coordination of assigned patients that include: pre-visit planning, workflow to ensure care completion prior to visit whenever possible, after visit summary review with patients whenever appropriate, patient engagement to involve the patients in activities to improve their health, and patient education.
Work in collaboration with inpatient Care Management and Coordination teams to ensure warm handoffs are provided for patients coming to the ED, hospital or who have recently been discharged from the hospital.
Utilize Quality Improvement plan for reporting and improvement strategies, (PDSA) and Lean Daily Management (LDM).
Attend staff and committee meetings including office based PCMH meetings and care management meetings.
GBMC Values
Respect Treats others with fairness, kindness, and respect for personal dignity and privacy. Listens and responds appropriately to others’ needs, feelings, and capabilities.
Excellence Meets and/or exceeds customer expectations. Actively pursues learning and self-development. Pays attention to detail; follows through.
Accountability Sets a positive, professional example for others. Takes ownership of problems and does what is needed to solve them. Appropriately plans and utilizes required resources for various job duties. Reports to work regularly and on time.
Teamwork Works cooperatively and collaboratively with others for the success of the team. Addresses and resolves conflict in a positive way. Seeks out the ideas of others to reach the best solutions. Acknowledges and celebrates the contribution of others.
Ethical Behavior Demonstrates honesty, integrity and good judgment. Respects the cultural, psychosocial, and spiritual needs of patients/families/coworkers.
Results Embraces change and improvement in the work environment. Continuously seeks to improve the quality of products/services. Displays flexibility in dealing with new situations or obstacles. Achieves results on time by focusing on priorities and manages time efficiently.
Pay Range $16.79 - $24.37
COVID-19 Vaccination All applicants must be fully vaccinated against Covid-19 or obtain a GBMC approved medical or religious exemption prior to starting employment at GBMC Healthcare, to include Gilchrist and GBMC Health Partners.
Equal Employment Opportunity GBMC HealthCare and its affiliates are Equal Opportunity employers. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity and expression, age, national origin, mental or physical disability, genetic information, veteran status, or any other status protected by federal, state, or local law.
Seniority level Mid-Senior level
Employment type Full-time
Job function Other
Industries Hospitals and Health Care
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Education
High School Graduate or higher
Experience
3 years Medical Office experience and experience navigating the healthcare system
Skills
Knowledge of medical and insurance terminology
Skill in oral and written communication to address inter- and intradepartmental concerns, solve problems and address conflict.
Skill in problem solving using available resources in innovative ways.
Customer service
Computer and personal productivity skills to enable effective use of EMR, e-mail, the internet, word processing, spreadsheets, presentation and database packages.
Analytical skills necessary to prepare and interpret reports
Navigating the health care system and providing resources to patients.
Demonstrate problem solving skills and the ability to research and evaluate innovative ways to use community resources
Patient & Workplace Safety
Employee has knowledge and understanding of patient and workforce safety as it relates to job duties.
Patient Population
Demonstrates competency in the delivery of care and applies the knowledge to meet age-specific needs if applicable.
Principal Duties and Responsibilities
Assist in the design and implementation of population health management reports for gaps in care monitoring.
Generate patient reports from the organization’s electronic health record system to identify gaps in care and target patient care coordination outreach efforts.
Review and monitor open care gaps from the targeted EMR chart review and payer reports. Review practice based EMR to collect proof of care gaps closure. Capture and upload care gap documentation to the EMR.
Work with various insurance carriers to identify gaps in care for patient panel and work collaboratively with the Ambulatory care teams to ensure seamless patient outreach.
Review risk-stratified lists of patients across Medicare, Medicaid, and Commercial insurers to prioritization of patient needs for access to community supports and services.
Perform outbound reminder telephone calls/Letters, My Chart Messages for targeted Quality Care Initiatives in an effort to increase scores related to measures based on care gap reports.
Promote Utilization Of Timely Preventative Care And Work With The Care Team To Prevent Unnecessary Emergency Department Visits And Hospital Admissions
Utilizing CRISP: Notification system for ED and hospital admissions.
Communicating with local hospitals to get the medical discharge summaries.
Collaborating with the RN Care Managers and Providers for medication reconciliation and Hospital Follow-up appointments.
Working high-utilizer panel of patients with multiple ED/Hospital Admissions. Working with multi-disciplinary care team (RN Care Manager, Behavioral Health Consultant, PCP, etc) to come up with plan of care to reduce hospital visits.
Coverage of care coordination work in the ambulatory primary care practice setting will include, but not be limited to:
Identifying Social Determinants of Health (SDOH) which include social, medical, financial, needs and barriers) and connecting patients and families with community supports and services.
Executing standing orders for tests and preventative services.
Managing transitions of care and referrals to specialists.
Anticipating the needs of the patient panel, ensuring that the necessary documentation and pre-visit planning is completed or requested before patient visits.
Handling urgent on-call patient needs after hours by provider on call
Completing medical record reconciliations to ensure testing, medications, office visits are current
Work with care teams as a resource on care coordination of assigned patients that include: pre-visit planning, workflow to ensure care completion prior to visit whenever possible, after visit summary review with patients whenever appropriate, patient engagement to involve the patients in activities to improve their health, and patient education.
Work in collaboration with inpatient Care Management and Coordination teams to ensure warm handoffs are provided for patients coming to the ED, hospital or who have recently been discharged from the hospital.
Utilize Quality Improvement plan for reporting and improvement strategies, (PDSA) and Lean Daily Management (LDM).
Attend staff and committee meetings including office based PCMH meetings and care management meetings.
GBMC Values
Respect Treats others with fairness, kindness, and respect for personal dignity and privacy. Listens and responds appropriately to others’ needs, feelings, and capabilities.
Excellence Meets and/or exceeds customer expectations. Actively pursues learning and self-development. Pays attention to detail; follows through.
Accountability Sets a positive, professional example for others. Takes ownership of problems and does what is needed to solve them. Appropriately plans and utilizes required resources for various job duties. Reports to work regularly and on time.
Teamwork Works cooperatively and collaboratively with others for the success of the team. Addresses and resolves conflict in a positive way. Seeks out the ideas of others to reach the best solutions. Acknowledges and celebrates the contribution of others.
Ethical Behavior Demonstrates honesty, integrity and good judgment. Respects the cultural, psychosocial, and spiritual needs of patients/families/coworkers.
Results Embraces change and improvement in the work environment. Continuously seeks to improve the quality of products/services. Displays flexibility in dealing with new situations or obstacles. Achieves results on time by focusing on priorities and manages time efficiently.
Pay Range $16.79 - $24.37
COVID-19 Vaccination All applicants must be fully vaccinated against Covid-19 or obtain a GBMC approved medical or religious exemption prior to starting employment at GBMC Healthcare, to include Gilchrist and GBMC Health Partners.
Equal Employment Opportunity GBMC HealthCare and its affiliates are Equal Opportunity employers. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity and expression, age, national origin, mental or physical disability, genetic information, veteran status, or any other status protected by federal, state, or local law.
Seniority level Mid-Senior level
Employment type Full-time
Job function Other
Industries Hospitals and Health Care
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