POPULATION HEALTH COORDINATOR
- Follow established PCC workflow for utilization and self-management support
- Participate in PCMH activities which include but are not limited to: hospital discharge follow-up, care planning, coordination of services, and communication between care providers
- Collaborate with patient’s medical/health and community-based providers to establish mutual goal-setting including patients and their families/caregivers, utilizing self-management tools.
- Provide outreach, care management and education for disease self-management per patient centered goals.
- Identify, document, and mitigate patient barriers to improved outcomes.
- Monitor and evaluate the services and community based resources necessary to respond to the individual member’s health needs.
- Provides telephonic and or in-practice outreach, disease management and/or case management, education, and other clinically based activities for target populations.
- Conduct assessments, develop nursing treatment plans and interventions and set goals for treatment plans/behavioral modifications within the scope of licensure in collaboration with other care providers
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