Greater Baltimore Medical Center (GBMC)
Care Coordinator for Population Health
Greater Baltimore Medical Center (GBMC), Towson, Maryland, United States, 21286
Overview
The Care Coordinator for Population Health is responsible for ensuring compliance with the quality goals and metrics set forth by the health system and various insurance carriers. This individual will assist in the design and implementation of population health management reports related to monitoring for gaps in care and care coordination activities. The Care Coordinator will generate and review patient reports from the organization\'s electronic health record system to identify gaps in care and target patient care coordination outreach efforts. The primary responsibilities are to promote population health management and robust quality performance through data and reporting, oversee coordination of care activities for patients in need, and link patients to health care services, community resources, and social supports. The role collaborates with the Practice Manager, Lead Physician, RN Care Manager, Behavioral Health Consultant and other care team members within the ambulatory primary care setting. The Care Coordinator for Population Health may also 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 prioritize patient needs for access to community supports and services.
Perform outbound reminder telephone calls/letters, My Chart Messages for targeted Quality Care Initiatives to improve scores related to care gap reports.
Promote utilization of timely preventative care and work with the care team to prevent unnecessary Emergency Department visits and Hospital Admissions by:
Utilizing CRISP: Notification system for ED and hospital admissions.
Communicating with local hospitals to obtain medical discharge summaries.
Collaborating with the RN Care Managers and Providers for medication reconciliation and Hospital Follow-up appointments.
Working with high-utilizer patients with multiple ED/Hospital Admissions and with a multi-disciplinary care team to plan care to reduce hospital visits.
Coverage of care coordination work in the ambulatory primary care practice setting includes:
Identifying Social Determinants of Health (SDOH) and connecting patients 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 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, and office visits are current
Working with care teams as a resource on care coordination of assigned patients, including pre-visit planning, workflow to ensure care completion prior to visit, post-visit summary review with patients, patient engagement, and patient education.
Collaborating with inpatient Care Management and Coordination teams to ensure warm handoffs for patients coming to the ED, hospital, or recently discharged.
Utilizing Quality Improvement plans (PDSA) and Lean Daily Management (LDM).
Attending 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.
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; takes ownership to solve problems; appropriately plans and utilizes required resources.
Teamwork: Works cooperatively with others; addresses and resolves conflict; seeks ideas from others; acknowledges contributions.
Ethical Behavior: Demonstrates honesty, integrity and good judgment; respects cultural, psychosocial, and spiritual needs of patients and coworkers.
Results: Sets goals and measures outcomes; embraces change and continuous improvement; achieves results on time by prioritizing and managing time.
Pay Range $16.79 - $24.37
Final salary offer will be based on the candidate\'s qualifications, education, experience and alignment with our organizational needs.
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.
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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 prioritize patient needs for access to community supports and services.
Perform outbound reminder telephone calls/letters, My Chart Messages for targeted Quality Care Initiatives to improve scores related to care gap reports.
Promote utilization of timely preventative care and work with the care team to prevent unnecessary Emergency Department visits and Hospital Admissions by:
Utilizing CRISP: Notification system for ED and hospital admissions.
Communicating with local hospitals to obtain medical discharge summaries.
Collaborating with the RN Care Managers and Providers for medication reconciliation and Hospital Follow-up appointments.
Working with high-utilizer patients with multiple ED/Hospital Admissions and with a multi-disciplinary care team to plan care to reduce hospital visits.
Coverage of care coordination work in the ambulatory primary care practice setting includes:
Identifying Social Determinants of Health (SDOH) and connecting patients 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 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, and office visits are current
Working with care teams as a resource on care coordination of assigned patients, including pre-visit planning, workflow to ensure care completion prior to visit, post-visit summary review with patients, patient engagement, and patient education.
Collaborating with inpatient Care Management and Coordination teams to ensure warm handoffs for patients coming to the ED, hospital, or recently discharged.
Utilizing Quality Improvement plans (PDSA) and Lean Daily Management (LDM).
Attending 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.
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; takes ownership to solve problems; appropriately plans and utilizes required resources.
Teamwork: Works cooperatively with others; addresses and resolves conflict; seeks ideas from others; acknowledges contributions.
Ethical Behavior: Demonstrates honesty, integrity and good judgment; respects cultural, psychosocial, and spiritual needs of patients and coworkers.
Results: Sets goals and measures outcomes; embraces change and continuous improvement; achieves results on time by prioritizing and managing time.
Pay Range $16.79 - $24.37
Final salary offer will be based on the candidate\'s qualifications, education, experience and alignment with our organizational needs.
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.
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