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- Denver, CO 80202
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Population Health Care Coordinator (RN)
Physician Health Partners, LLC • Denver, CO
Posted 26 days ago
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Position Summary: The Population Health Care Coordinator (PHCC) is a registered nurse who is responsible for managing the population health of the Medicare Advantage members. The PHCC is responsible for reviewing gaps in care data and ensure that targeted comprehensive care coordination services are rendered, in order to attain Triple Aim values and successfully close gaps in care. Provides direct outreach to members, via phone or on-site, to direct and/or oversee the delivery of clinical services for individuals with diabetes, high clinical gaps in care and low adherence to medication, in order to assure high quality, cost-effective clinical outcomes. Coordinates services with other health-related vendors for optimal patient care and satisfactory outcomes. Works closely with the care coordination, auditing and coaching teams and the Medical Directors
Communicates well both verbally and in writing, creates accurate and punctual reports, delivers presentations, shares information and ideas with others, has good listening skills.
- Collaborate with leadership, staff and partners to ensure coordinated delivery of services to clients.
- Work with cross-departmental teams to develop, implement, and manage clinical quality initiatives.
- Effectively document and report project and program level updates to varying levels of staff, executives, clients, and partners.
- Works closely with the Manager of Coordination to collaborate on best practices in providing care coordination services, prevent duplication of services to the member in the event a member is already working with a PHPprime Care Coordinator and establish criteria for referral to Care Coordination team when longitudinal and/or intensive care plans are necessary for the member to be successful.
Breaks down problems into smaller components, understands underlying issues, can simplify and process complex issues, understands the difference between critical details and unimportant facts.
- Support Operations and key stakeholders in achieving quality improvement through development of program performance metrics, driving process to produce outcomes and implementation of quality management tools and techniques to facilitate patient care across care settings.
Manages a fair workload, volunteers for additional work, prioritizes tasks, develops good work procedures, manages time well, handles information flow.
- Utilize data from claims, EHR, and a population health tool to understand patient case history and refer patients with high complexity to the Care Coordination team.
- Develop full-cycle project plans for key clinical quality initiatives management of position objectives.
- Provide direct outreach to members, independently complete assessments and care plans with Medicare Advantage members
Seeks out and accepts feedback, is a proactive learner, takes on tough assignments to improve skills, keeps knowledge and skills up-to-date, turns mistakes into learning opportunities.
- Orient new staff and customers on quality initiatives project goals and deliverables
- Enhance professional growth by learning new skills and techniques that will enhance programs and goals.
Builds customer confidence, is committed to increasing customer satisfaction, sets achievable customer expectations, assumes responsibility for solving customer problems, ensures commitments to customers are met, solicits opinions and ideas from customers, responds to customers.
- Build and maintain relationships with key internal and external stakeholders.
- Interfaces with members using motivational interviewing and reflective listening skills in order to develop and understand/identify both strengths and of barriers to meeting health related goals, develop a client specific wellness care plans, make appropriate referrals to community services and monitor progress. Set goals for health improvement, and monitor goal attainment.
Understands duties and responsibilities, has necessary job knowledge, has necessary technical skills, understands company mission/values, keeps job knowledge current, is in command of critical issues.
- Understands CMS Stars Measures, HEDIS, and NQF metrics
- Able to engage and empower patients through technics like motivational interviewing and self-management support
- Clinical assessment, care planning, evidence based interventions monitoring and support and patient empowerment
- Interdisciplinary care team and provider engagement
- Able to translate measures to care coordination strategies and initiatives
- Other duties as assigned
- RN with valid license in good standing. (Required Licensure or Certification for this position must be maintained by the employee as defined by the company policies and procedures)
- Minimum of three years quality improvement experience with an established track record of leading successful process improvement initiatives, including implementing behavioral and system changes in a healthcare setting
- Strong computer skills: data entry, word processing, and spreadsheet manipulation.
- Experience working with physicians and physician office staff
- Knowledge of provider office workflow processes, healthcare delivery systems and healthcare trends
- Knowledge of business and project management principles
- Knowledge of quality improvement methods, tools and techniques
- Highly organized with proven project management skills
- Skills in using information and data to effectively identify, implement and track projects
- Using logic and reasoning to identify the strengths and weaknesses of alternative solutions, conclusions or approaches to problems
- Identifying complex problems and reviewing related information to develop and evaluate options and implement solutions
- Effective verbal and written communication and ability to tailor message to the audience
- Demonstrated ability to lead and facilitate meetings and teams
- Ability to work effectively by establishing effective work relationships with physicians, office staff, PHP employees and clients Boards and Committees. Ability to understand strategic direction of clients and apply to current role
- Ability to present data & results in a manner that is easy to understand and facilitates process improvement at all levels
- A valid unrestricted Colorado drivers’ license.
- Reliable and insured vehicle.
- Mobile Device for work purposes as defined by the company policies and procedures.
Physical Demands and Work Environment: Requires sitting and standing associated with a busy office environment as well as stooping and bending to file and maintain orderliness; mobility to complete errands. Must be able to assess, evaluate, and respond to acute issues in a timely, competent manner. Must be able to function with frequent interruptions, accept change and able to prioritize activities when faced with competing demands.
Minimum of three years quality improvement experience with an established track record of leading successful process improvement initiatives, including implementing behavioral and system changes in a healthcare setting
Strong computer skills: data entry, word processing, and spreadsheet manipulation.
Experience working with physicians and physician office staff
Knowledge of provider office workflow processes, healthcare delivery systems and healthcare trends
Knowledge of business and project management principles
Knowledge of quality improvement methods, tools and techniques
Highly organized with proven project management skills
Skills in using information and data to effectively identify, implement and track projects
Using logic and reasoning to identify the strengths and weaknesses of alternative solutions, conclusions or approaches to problems
Identifying complex problems and reviewing related information to develop and evaluate options and implement solutions
Effective verbal and written communication and ability to tailor message to the audience
Demonstrated ability to lead and facilitate meetings and teams
Ability to work effectively by establishing effective work relationships with physicians, office staff, PHP employees and clients Boards an
and Committees. Ability to understand strategic direction of clients and apply to current role
Ability to present data & results in a manner that is easy to understand and facilitates process improvement at all levels
A valid unrestricted Colorado drivers license.
Reliable and insured vehicle.
Mobile Device for work purposes as defined by the company policies and procedures.