Position: Population Health Care Coordinator

Department: Quality Improvement

Reports To: Director of Quality Improvement

Locations

Belmont Cragin

5635 W Belmont Ave

Chicago, IL 60634

West Town

1431 N Western Ave, Suite 401

Chicago, IL 60622

Position Summary

The Population Health Care Coordinator will provide direct service under the West Side Health Equity Collaborative Program. The coordinator will enroll and provide care coordination services to patients with Medicaid and uninsured patients residing in Chicago’s West Side zip codes. The coordinator will work with patients to improve self-management of diabetes, hypertension and mild/moderate depression through assessment, enhanced self-awareness, education, self-monitoring and eliminating barriers to self-care by screening and addressing social determinants of health. In addition, the Population Health Care Coordinator will serve as a bridge between the patient, the medical system, and community-based organizations by building trusting relationships with community members served by the program.

Duties And Responsibilities

Conduct proactive outreach to patients who live in one of the ten targeted zip codes who have a qualifying condition(s) of hypertension, diabetes, and/or depression and children with adverse childhood experience to promote the program and enroll them into the program
Collaborate with the clinic staff and care team to increase awareness of WSHEC and create effective methods for communication and collaboration such as warm hand offs and referrals
Accept referrals of enrolled individuals from the hospital emergency department care navigators.
Accept referrals of enrolled individuals from community-based organizations.
Conduct depression screenings using the PHQ-2 and PHQ-9 screening tools and working with the care team to refer the patient to behavioral health or other specialty care if depression is identified
Monitor patients with hypertension for recent self-monitored blood pressure readings, collect readings and share with provider and care team
Monitor patients with diabetes for frequent A1c results and schedule lab visits when due
Conduct periodic rescreening using the health risk screening tool to determine progress in addressing social determinants of health and identify any new ones
Use a worklist to identify and re-engage patients who are not participating as expected in the disease management program
Address patient’s social determinants of health (SDOH) and barriers to care
Identify and engage with community-based organizations (CBOs) through the electronic registry and bidirectional communication with CBOs using the Community Connect secure messaging portal
Provide education, coaching, and motivational interviewing to support the patient in the self-management of their chronic conditions, including but not limited to the use of glucometers and blood pressure monitors for self-monitoring
Utilize MHN Connect to monitor recent emergency department visits and hospitalizations and pharmacy fill data and be prepared to address that utilization information during encounters
Document all encounters, outreaches, and other notes in Athena and MHN Connect
Participate in case reviews with other care team members (nurses, behavioral health providers, PCPs, pharmacists, social workers, care managers of high-risk enrollees as appropriate) of enrollees who are not making progress toward self-management goals. Provide the care team with patient updates and ensure the care plan is consistently updated and integrated with disease management information
Facilitate treatment plan changes for patients who are not improving as expected in consultation with the PCP. These may include changes in medications, treatments, or appropriate referrals for clinically indicated services outside the primary care clinic (e.g., social services such as housing assistance, vocational rehabilitation, subspeciality, mental health specialty care, substance abuse treatment, etc.).
Other duties as assigned.

Required Knowledge, Experience, Or Licensure/Registration

Bachelor’s degree in related field preferred.
One (1) to three (3) years of experience, preferred in social services. Background in a community health setting is highly preferred.
Ability to use MS Office programs, including MS Word, Excel and Outlook.
Bilingual in English/Spanish required.

Physical Demands

Must be able to remain in a stationary position 50% of the time.
Must be able to move around the clinic site 50% of the time.
Constantly operates a computer, computer printer, copy machine, and telephone.
Occasionally positions self to maintain exertion of physical strength to move objects of 10

pounds from one level to another.

Must be able to cover other shifts as necessary

Comprehensive Health Insurance Benefits Through BCBS Of IL

Health Insurance (HMO/PPO)
Dental Insurance (HMO/PPO)
Vision Insurance
Short/Long-Term Disability Insurance
Group Life Insurance

Other Benefits Include

403(b) Retirement plan with employer match
Pension Plan
Voluntary Life/ AD&D
Flexible Spending/Dependent Care Accounts
Annual CME Allowance and CME PTO (Providers Only)
Paid Time Off
3 Personal days per calendar year
7 Holidays per calendar year
Employee Assistance Program
Tuition Assistance Program
Off-the-job Accident Coverage
Employee Referral Program
Internal Growth Opportunities

PrimeCare Community Health is part of the National Health Service Corps, as such, you would be able to participate in their Loan Repayment Program. For more information, please visit their website at https://bhw.hrsa.gov/loans-scholarships

In accordance with Illinois Executive order 2021-20 (COVID-19 No.87) effective on August 26, 2021, in conjunction with the Federal CDC guidelines, COVID vaccinations are now a requirement for PrimeCare Community Health as well as many other Healthcare Organizations. Proof of full vaccination is required prior to the beginning date of employment. If you have a medical or religious contraindication, please inform Human Resources when the offer is extended.

PrimeCare Health is firmly committed to creating a diverse workplace and is proud to provide equal employment opportunities to all applicants. Therefore, PrimeCare does not discriminate on the basis of creed, color, national origin, sex, gender identity, sexual orientation, age, religion, marital or parental status, alienage, disability, political affiliation or belief, military or military discharge status.

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Population Healthcare Coordinator