Patient Engagement Coordinator

Neighborhood Health is an innovative network of 13 community health centers in Nashville, Lebanon, Gallatin, and Springfield, Tennessee. We provide comprehensive primary care, integrated behavioral health, and dental services to almost 30,000 patients. Our patients primarily include immigrants, residents of public housing, individuals experiencing homelessness, and persons living with addiction. As a federally qualified health center, we provide care without regard to health insurance or a patient's ability to pay. We also strive to improve our Patient Centered Medical Home (PCMH) model to ensure all of our patients get the right high-quality care, at the right place, and at the right time.

Nature of Position: Must be able to work in a Patient Centered Medical Home model. Must facilitate partnerships between patients, providers and health teams with focus on care coordination and integration of treatment internally and externally. Must work diligently to assure that services are accessible, continuous, comprehensive, coordinated, compassionate, and culturally effective. Must be committed to eliminating barriers to care that is centered on the needs and convenience of patients above all other factors.

Summary of Duties:

• Engage attributed patients to connect them to Neighborhood Health services, as part of value-based care programs.
• Works in insurance payer portals to access attributed patients and document care coordination.
• Tracks no-shows of new patient visits for attributed members to coordinate timely follow up.
• Engage established patients though all available modalities (i.e., text message, email, telephone, and letters) to schedule primary care appointments in order to close gaps-in-care.
• Follows guidelines to identify attributed members in value-based programs who should be reviewed for possible removal from panel.
• Ensures new patients are aware of benefits they are entitled to through their insurance.
• Works in population health tools and tracking spreadsheets to monitor patient engagement as part of daily operations.
• Coordinates continuity of patient care with patients and families following hospital discharges and ER visits.
• Promotes clear communication amongst a care team and treating clinicians by ensuring awareness regarding patient reasons for visit.
• Evaluates clinical care, utilization of resources, and development of new clinical tools, forms, and procedures.
• Participates in team meetings, payer meetings, and quality improvement initiatives.
• Other duties as assigned.

Education and Experience:

• Essential:

• High School diploma required

• Proficient in learning and navigating different systems.

• Proficient computer skills, including Microsoft Office (specifically Word and Excel)

• Self-disciplined, energetic, passionate, innovative

• A team player that can follow a system and protocol to achieve a common goal

• Highly organized and well-developed oral and written communication skills

• Demonstrates sound judgment, decision-making and problem-solving skills

• Able to maintain confidentiality with all aspects of information in accordance with practice, State and Federal regulations

• Confidence to communicate and outreach to patients and representatives from insurance payers that we hold value-based-care agreements with.

• Preferred:

• Bilingual in English and Spanish

• Experience working in a value-based-care model with an understanding of gaps-in-care and quality measures.

• 1 year in a Patient-Centered Medical Home setting or knowledge of the Patient-Centered Medical Home initiative

• 1 year experience as a Community Health Worker or Care Coordinator.

Reports to: Director of Policy, Compliance, and Innovation

Position: Full-time

EOE D/V