Population Care Coordinator

Support and participates in the Patient-centered Medical Home (PCMH) concepts of care coordination and team- based care. Assess, plan, implement, coordinate, monitor and evaluate healthcare options and services with the goal of increasing the likelihood of improvement to the health status of identified populations across the continuum. •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...