MCHC is currently seeking a regular, full-time Population Health Care Coordinator. This position is available at our State Street Admin building. The Care Coordinator is responsible for engaging and assisting patients on their journey towards sustainable long-term improvements. He or she will partner with clients seeking self-directed, lasting changes that are aligned with the patients’ values and their plan of care to promote health and wellness. The Care Coordinator will facilitate client education, support groups, and engage targeted clients who may otherwise be lost to care.

Primary Duties include:

• Maintains confidentiality and adheres to all ethical standards of practice. Demonstrates professionalism and discretion when caring for patients. Copes with complex situations in a professional and positive manner, while maintaining the integrity of the organization.
• Supports MCHC in the advancement of the Quadruple Aim: improving health outcomes, improving the patient and staff experience, and lowering healthcare costs.
• Maintains an understanding their role in quality improvement initiatives such as PCMH, Partnership QIP, UDS and other regulatory oversight. Works closely with the Director of Population Health to develop program goals, celebrate program successes, and overcome operational challenges.
• Works with Population Health Director and Care Manager(s) to assist in the maintenance of population health registries and performing designated outreach. Schedules patients as needed to meet due or overdue health maintenance profiles. Creates orders where trained/appropriate. Follows all MCHC policies, procedures, and workflows to ensure standards of care are met.
• Works collaboratively with Care Teams, Providers, Patient Financial Services, Billing, Operations, Risk Management, and community-based organizations to advocates for patients, connect them to available services and facilitate resolution of potential barriers.
• Demonstrates strong knowledge of available resources and seek out additional resources as needed. Fosters positive working relationships between resources and MCHC.
• Using motivational interviewing techniques, engages patients actively participate in their medical care.
• Documents Care Coordination activities in the electronic health record (EHR) and other electronic systems, to provide needed information for care teams and advance the goals of the Population Health Department. Able to identify gaps in workflows and make recommendations for improved processes.
• Maintains patient registries within the EHR and facilitates patient tracking to meet clinical quality measures. Ability to run reports and conduct data analytics to meet departmental goals. Regularly reports registry and tracking information to care teams, Care Manager, and Population Health Director.
• Coordinates appropriate referrals to MCHC Care Management and/or departmental programs as needed. Attends and constructively participates in Care Management meetings, case conferences, and trainings when required.
• Conducts patient outreach and follow-up calls in both English and Spanish, with support from bilingual staff or language line as needed.
• In collaboration with Director of Population Health, works to implement and maintain wellness initiatives, support group curriculums, program materials, workflows, and protocols.
• In collaboration with the Director of Population Health, explores opportunities for patient outreach and engagement through health information technology, including patient portal, SMS texting, remote patient monitoring, etc.
• Follows Universal Precautions, OSHA standards and is familiar with reporting adverse conditions including injuries and occupational exposure.
• When applicable, assumes professional accountability for continuing education and maintains employee education record and appropriate licensure/certifications.
• Traveling to different sites

Benefits Offered:

• Medical, Dental, & Vision Insurance
• Paid Time Off
• Life Insurance
• 401k Match
• Flexible Spending Account
• And more...

Minimum Qualifications:

• Experience or educations related to Health or Human services, health promotion, health education, nursing, nutrition, medical assistant, other health related field.
• Knowledge of specific disease and lifestyle related topics such as smoking cessation, nutrition, substance use disorder, social determinants of health, stress reduction and chronic conditions.
• Have and maintain a valid California Driver’s License. Must carry liability/bodily injury on his/her automobile(s) used for work.

Other Preferred Qualifications:

• Certified Medical Assistant or education in medical, social work, sociology, health and wellness or related field.
• Knowledge of group process, psychosocial concepts, support systems, stages of change, Motivational Interviewing, ethical standards, and medical and behavioral health care systems.