Atrium Health
Population Health Patient Coordinator
Atrium Health, North Wilkesboro, North Carolina, United States, 28674
Wake Population Health - Population Health
Full time
Benefits Eligible: Yes
Hours Per Week: 40
Schedule Details/Additional Information: Weekdays
Pay Range $21.45 - $32.20
Make a meaningful impact in the lives of patients and communities by becoming a vital connector in the healthcare system. As a Population Health Patient Coordinator, you will serve as a cultural liaison, health navigator, wellness promoter, and dedicated advocate—helping individuals access the health and social resources they need to thrive. In this role, you will strengthen continuity of care across ambulatory clinics, build trusted relationships, address social determinants of health in culturally competent ways, and work alongside a dynamic interdisciplinary team to support high‑risk, vulnerable patients. If you’re passionate about equity, connection, and empowering others, this is an opportunity to create lasting change.
Essential Functions
Identify and utilize cultural and community resources; establish and maintain relationships with local service providers. Collaborate with care managers and interdisciplinary team members to support the development and execution of comprehensive care plans. Receive and manage referrals and assigned tasks for screening, coordination, and monitoring of social (non‑clinical) needs. Facilitate appropriate use of services and smooth care transitions by educating families, communicating between patients and providers, and maintaining regular contact with both. Provide social care support for a defined patient panel within Advanced Medical Home practices. Use targeted reports and screening tools to identify patients who would benefit from care coordination and connection to community resources; adjust frequency and intensity of support based on patient need. Engage individuals to build on strengths and work toward health, social, and personal goals. Assist families in identifying and prioritizing needs; schedule and conduct home, school, or community visits as needed. Build trusting relationships through respect for diversity, active listening, casual counseling, and encouragement. Identify elements of healthy lifestyle behaviors and reinforce the importance of self‑management. Educate patients on self‑management of health conditions and support the development of healthier habits and effective use of the healthcare system. Document all patient engagement, assessments, and follow‑up in the EMR accurately and promptly. Facilitate access to community resources such as housing, food, clothing, prenatal and parenting classes, life‑skills support, and mental health services. Work to reduce cultural and socioeconomic barriers between patients and the healthcare system. Perform other related duties as assigned to support patient and community health. Education & Certification Requirements
High School Diploma or GED (required) Bachelor’s degree in a relevant human services field (preferred) CPR certification within 30 days of hire (required) Completion of a Community Health Worker (CHW) Training course within one year of hire (required) Community Health Worker Certification within one year of hire (required) Schedule
Monday–Friday Our Commitment to You
Advocate Health offers a comprehensive suite of Total Rewards: benefits and well‑being programs, competitive compensation, generous retirement offerings, programs that invest in your career development and so much more – so you can live fully at and away from work, including: Compensation
Base compensation listed within the listed pay range based on factors such as qualifications, skills, relevant experience, and/or training Premium pay such as shift, on call, and more based on a teammate's job Incentive pay for select positions Opportunity for annual increases based on performance Benefits and more
Paid Time Off programs Health and welfare benefits such as medical, dental, vision, life, and Short‑ and Long‑Term Disability Flexible Spending Accounts for eligible health care and dependent care expenses Family benefits such as adoption assistance and paid parental leave Defined contribution retirement plans with employer match and other financial wellness programs Educational Assistance Program About Advocate Health
Advocate Health is the third‑largest nonprofit, integrated health system in the United States, created from the combination of Advocate Aurora Health and Atrium Health. Providing care under the names Advocate Health Care in Illinois; Atrium Health in the Carolinas, Georgia and Alabama; and Aurora Health Care in Wisconsin, Advocate Health is a national leader in clinical innovation, health outcomes, consumer experience and value‑based care. Headquartered in Charlotte, North Carolina, Advocate Health services nearly 6 million patients and is engaged in hundreds of clinical trials and research studies, with Wake Forest University School of Medicine serving as the academic core of the enterprise. It is nationally recognized for its expertise in cardiology, neurosciences, oncology, pediatrics and rehabilitation, as well as organ transplants, burn treatments and specialized musculoskeletal programs. Advocate Health employs 155,000 teammates across 69 hospitals and over 1,000 care locations, and offers one of the nation’s largest graduate medical education programs with over 2,000 residents and fellows across more than 200 programs. Committed to providing equitable care for all, Advocate Health provides more than $6 billion in annual community benefits. The Patient Coordinator is an essential member of the healthcare team who will serve as a cultural liaison, health navigator, health and wellness promoter, and advocate. Facilitate access to health and social services to improve the health outcomes of individuals and their communities by addressing social determinants of health in culturally competent ways.
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Identify and utilize cultural and community resources; establish and maintain relationships with local service providers. Collaborate with care managers and interdisciplinary team members to support the development and execution of comprehensive care plans. Receive and manage referrals and assigned tasks for screening, coordination, and monitoring of social (non‑clinical) needs. Facilitate appropriate use of services and smooth care transitions by educating families, communicating between patients and providers, and maintaining regular contact with both. Provide social care support for a defined patient panel within Advanced Medical Home practices. Use targeted reports and screening tools to identify patients who would benefit from care coordination and connection to community resources; adjust frequency and intensity of support based on patient need. Engage individuals to build on strengths and work toward health, social, and personal goals. Assist families in identifying and prioritizing needs; schedule and conduct home, school, or community visits as needed. Build trusting relationships through respect for diversity, active listening, casual counseling, and encouragement. Identify elements of healthy lifestyle behaviors and reinforce the importance of self‑management. Educate patients on self‑management of health conditions and support the development of healthier habits and effective use of the healthcare system. Document all patient engagement, assessments, and follow‑up in the EMR accurately and promptly. Facilitate access to community resources such as housing, food, clothing, prenatal and parenting classes, life‑skills support, and mental health services. Work to reduce cultural and socioeconomic barriers between patients and the healthcare system. Perform other related duties as assigned to support patient and community health. Education & Certification Requirements
High School Diploma or GED (required) Bachelor’s degree in a relevant human services field (preferred) CPR certification within 30 days of hire (required) Completion of a Community Health Worker (CHW) Training course within one year of hire (required) Community Health Worker Certification within one year of hire (required) Schedule
Monday–Friday Our Commitment to You
Advocate Health offers a comprehensive suite of Total Rewards: benefits and well‑being programs, competitive compensation, generous retirement offerings, programs that invest in your career development and so much more – so you can live fully at and away from work, including: Compensation
Base compensation listed within the listed pay range based on factors such as qualifications, skills, relevant experience, and/or training Premium pay such as shift, on call, and more based on a teammate's job Incentive pay for select positions Opportunity for annual increases based on performance Benefits and more
Paid Time Off programs Health and welfare benefits such as medical, dental, vision, life, and Short‑ and Long‑Term Disability Flexible Spending Accounts for eligible health care and dependent care expenses Family benefits such as adoption assistance and paid parental leave Defined contribution retirement plans with employer match and other financial wellness programs Educational Assistance Program About Advocate Health
Advocate Health is the third‑largest nonprofit, integrated health system in the United States, created from the combination of Advocate Aurora Health and Atrium Health. Providing care under the names Advocate Health Care in Illinois; Atrium Health in the Carolinas, Georgia and Alabama; and Aurora Health Care in Wisconsin, Advocate Health is a national leader in clinical innovation, health outcomes, consumer experience and value‑based care. Headquartered in Charlotte, North Carolina, Advocate Health services nearly 6 million patients and is engaged in hundreds of clinical trials and research studies, with Wake Forest University School of Medicine serving as the academic core of the enterprise. It is nationally recognized for its expertise in cardiology, neurosciences, oncology, pediatrics and rehabilitation, as well as organ transplants, burn treatments and specialized musculoskeletal programs. Advocate Health employs 155,000 teammates across 69 hospitals and over 1,000 care locations, and offers one of the nation’s largest graduate medical education programs with over 2,000 residents and fellows across more than 200 programs. Committed to providing equitable care for all, Advocate Health provides more than $6 billion in annual community benefits. The Patient Coordinator is an essential member of the healthcare team who will serve as a cultural liaison, health navigator, health and wellness promoter, and advocate. Facilitate access to health and social services to improve the health outcomes of individuals and their communities by addressing social determinants of health in culturally competent ways.
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