Planned Care Coordinator

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.

• 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.

• Develop and deliver training sessions on quality improvement workflows, including clinical best practices, accurate data entry, and performance improvement strategies.
• 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.

• 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.

• 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.

• 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

• 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…