Population Health Coordinator

Georgia Mountains Health Services, Inc. Blue Ridge, Georgia, United States

FSLA Status: Exempt REPORTS TO: COO

Full-Time 40 hours per wk/M-F/ 8a-5p with flexibility Location: Blue Ridge, GA

Annual Salary Range: $55,000 - $65,000

Job Summary:

The Registered Nurse / Population Health Coordinator functions as an integral member of the patient care team and supports the delivery of high-quality, coordinated, patient-centered care. This position combines direct nursing responsibilities with population health management, preventive care, quality improvement, patient outreach, care coordination, and monitoring of quality program measures.

The position works collaboratively with providers, clinical staff, leadership, insurance representatives, and other external partners to identify patient needs, close gaps in care, improve health outcomes, and support organizational quality goals. Travel is required to all GMH offices. Company vehicles are provided for site location travel.

About GMH:

Georgia Mountains Health (GMH) is a non-profit, Federally Qualified Health Center (FQHC), mission driven organization, committed to providing compassionate and quality health care to families in North Georgia (Blue Ridge, Ellijay, Chatsworth and Dahlonega) . We believe in more than just treating patients and we are seeking a mission-oriented candidate who understands the nuances of an FQHC and practice of using UDS measures for quality health care improvement.

RESPONSIBILITIES

• Completes Annual Wellness Visits for qualifying patients, including scheduling, required screenings, medication reconciliation, updating documentation, billing for services, and completing other pertinent information.
• Uses data analytics, reports, and electronic health record information to identify, monitor, and address population health and insurance quality program measures and gaps in care.
• Develops and maintains collaborative relationships with insurance companies and other external partners and participates in meetings with insurance representatives to review quality measures, benchmarks, program requirements, and organizational performance.
• Coordinates and assists with patient outreach initiatives designed to improve preventive care, chronic disease management, quality measures, and completion of identified gaps in care.
• Provides clinical staff with appropriate educational materials and resources to support patient education, preventive health initiatives, and quality improvement efforts.
• Monitors quality measure performance, benchmarks, program standings, and potential or actual program payments associated with applicable insurance and quality programs.
• Reviews Care Plan Reports/DARCI and other available patient information to conduct pre-visit planning, identify gaps in care, determine needed services according to practice protocols, update patient charts with recent test results and correspondence, and obtain necessary medical records or other documentation.
• Assesses and prioritizes patient needs to ensure timely and appropriate care and provides clinical guidance and support utilizing professional nursing expertise and judgment.
• Communicates laboratory and diagnostic test results to patients and provides appropriate education, follow-up instructions, and information regarding next steps.
• Manages prescription refill requests and addresses inquiries from pharmacies regarding prescriptions and medications.
• Coordinates patient care with disease management, case management, and other appropriate programs and services.
• Performs chart reviews and extracts necessary clinical information and data for quality reporting, patient outreach, care coordination, and other assigned initiatives.
• Educates patients and families regarding the importance and benefits of preventive care, recommended screenings, chronic disease management, and completion of applicable quality measures.
• Encourages and supports the clinical patient care team in implementing preventive health care programs and maintaining a collaborative, team-based approach to health care delivery.
• Participates in the development, configuration, and improvement of the electronic health record to support clinical workflows, population health management, and clinical decision support, incorporating evidence-based guidelines when appropriate.
• Reviews EHR documentation for accuracy, completeness, and timely completion in accordance with organizational policies and established workflows.
• Identifies…