Planned Care Coordinator

Job Summary

This role of PLANNED CARE COORDINATOR Level II, offers an exciting opportunity to make a significant impact on the clinic's overall quality, performance improvement and patient care initiatives while supporting the growth and development of community health and quality improvement.

Seeking an individual to serve as a clinic-wide trainer specializing in quality improvement workflows, patient engagement, population health initiatives, and Epic EHR documentation. This role will be integral in educating and guiding clinical care coordination across the clinic to ensure adherence to best practices that improve patient care and clinic efficiency.

Key Responsibilities

Training & Education

• Develop and deliver training sessions on quality improvement workflows, including clinical best practices, accurate data entry, and performance improvement strategies.
• Educate clinical care coordination on population health concepts, with a focus on preventive care, chronic disease management, and addressing healthcare disparities.
• Provide hands-on training on Epic EHR workflows, ensuring accurate and efficient documentation of patient encounters, orders, and follow-up tasks.
• Train clinical care coordination on effective patient engagement techniques, emphasizing communication, empathy, and patient-centered care.
• Educate patients and caregivers on managing chronic conditions and the importance of preventive care.
• Advocate for patients by connecting them with appropriate services, including transportation, financial assistance, and mental health resources.
• Promote health literacy by providing easy-to-understand information to patients when needed.

Population Health Coordination and Program Development

• Assist in the creation and management of population health programs targeting specific patient groups, such as those with chronic diseases or high utilization.
• Collaborate with public health agencies, community organizations, and other stakeholders to address population health needs.
• Develop and implement strategies for managing patient populations within value-based care models.

Patient Outreach and Engagement

• Coordinate and perform outreach activities to engage patients in preventive screenings, immunizations, and wellness initiatives.
• Communicate with patients through calls, emails, and letters to remind them of appointments, follow-up care, and health screenings.
• Address barriers to care, including access to services, health literacy, and social determinants of health.

Quality Improvement

• Collaborate with the Quality Improvement and Population Health team to implement clinic-wide quality initiatives aimed at improving patient outcomes and care processes.
• Monitor and evaluate the effectiveness of training programs by tracking performance indicators such as documentation accuracy, patient engagement metrics, and compliance with quality standards.

Quality Improvement Initiatives

• Support the design and implementation of quality improvement initiatives aimed at improving population health outcomes.
• Assist in monitoring and evaluating the effectiveness of interventions and recommending adjustments as necessary.
• Ensure adherence to clinical guidelines and best practices across the care continuum.
• Assist with clinical workflow observations

Data Analysis and Reporting

• Collect, analyze, and interpret population health data to identify trends, gaps in care, and at-risk populations.
• Create reports and dashboards that provide actionable insights to providers and leadership teams.
• Monitor performance metrics related to preventive care, chronic disease management, and health outcomes.

Collaborative Support

• Act as a liaison between clinical care coordination staff and interdisciplinary teams to foster a culture of collaboration and continuous improvement.
• Provide ongoing support and mentorship to clinical care coordination staff, addressing challenges and offering guidance on workflow optimization.
• Work closely with primary care providers, specialists, care managers, and social workers to coordinate patient care.
• Participate in interdisciplinary team meetings to discuss population health initiatives and patient care strategies.
• Lead efforts to educate staff on population health principles, value-based care, and care management strategies.

Care Coordination

• Collaborate with healthcare providers and interdisciplinary teams to ensure high-risk patients receive appropriate follow-up care.
• Follow directions of plan of care patients with chronic conditions, focusing on preventative measures and disease management.
• Facilitate referrals to specialists, community resources, and other healthcare services as needed.

Documentation and Reporting

• Ensure compliance with all regulatory and organizational documentation standards in Epic EHR.
• Assist in the creation of user-friendly guides and resources for Epic documentation and workflow processes.
• Ensure all population health activities comply with relevant regulations, policies, and accreditation standards.
• Document patient interactions, care coordination efforts, and outcomes in the electronic health record (EHR) system.

Other Duties

• Other duties and/or locations as assigned.

Requirements

Qualifications

• 3+ years of experience in a clinical setting with experience in quality improvement initiatives.
• Proficient in Epic EHR and other clinical software systems (preferred)
• Strong communication, teaching, and mentoring skills.
• Ability to work effectively within an interdisciplinary team.

Skills and Competencies

• In-depth knowledge of healthcare quality improvement principles, including performance measurement and population health management.
• Expertise in Epic EHR workflows, with the ability to train others on system use and documentation standards.
• Optimal use of Microsoft Office Suite
• Excellent interpersonal skills, with a focus on patient engagement and team collaboration.
• Strong problem-solving abilities, particularly in workflow optimization and process improvement.

Physical Requirements

• Must be able to stand or sit for prolonged periods (at least 50% of the time)
• Visual acuity sufficient for frequent reading and computer use