DescriptionPOSITION SUMMARY:The Population Health Care Coordinator works in collaboration and partnership within an interdisciplinary team to manage chronic healthcare conditions for patients with two or more chronic conditions and tangential issues. This role will focus on Patient Centered Medical Home (PCMH), quality improvement, comprehensive care management services, value based care, and closing care gaps. The Population Health Care Coordinator will ensure transparent whole person care and will support patient activation in care, improved population health outcomes and increased health literacy. This position will work in the southwest area of the state splitting time between the Dayton Medical Center and Cincinnati Medical Center.MAJOR AREAS OF RESPONSIBILITIES: Promote timely access to appropriate and encompassing care in compliance with standards set forth through HRSA and NCQACreate and promote adherence to a care plan, developed in coordination with the patient, primary care provider and care teamCultivate and support primary care and specialty provider co-management with timely communication, inquiry, follow-up and integration of information into the care plan Increase continuity of care by supporting effective mechanisms in transitions of care and managing relationships with secondary and tertiary care providers and referralsIncrease patients' ability for self-management and shared decision-makingEstablish relationships with relevant community resources, resulting in the connection of patients to these resources with the goal of enhancing patient health and well-being, increasing patient satisfaction and reducing health care costs Assess patient health literacy and utilize effective strategies to increase understanding and activation in careAnticipate and meet or exceed all patient needs.Attend all Care Coordinator training courses/webinars and meetingsCollect and analyze population health outcomes and Provide feedback for the improvement of the Care Coordination ProgramAssist in identifying appropriate QI initiatives to improve health outcomes for general Primary Care and Specialty CareFacilitate, implement and evaluate QI activities to improve chronic care management among care teamsIncrease efficiencies through the use of improved workflows and integration of service delivery to address complexity of chronic disease management. Will participate in ongoing professional and personal development related to enhanced leadership activities and evidence-based practices Other duties as assigned.EDUCATION/LICENSURE:Required: RN Licensed in Ohio Required: Associate's Degree in any disciplineKnowledge, Skills, Abilities and other Qualifications:Knowledge of clinical quality indicators for Ryan White, FQHC, Meaningful Use and PCMH2-3 years of RN experience in a clinical settingEvidence of essential leadership, communication and counseling skillsHighly organized with ability to keep accurate notes and recordsExperience with Quality Improvement and change management preferredMust have sensitivity to, interest in and competence in cultural differences, HIV/AIDS, minority health, and a demonstrated competence in working with persons of color, and LGBTQ communities.Proficiency in all Microsoft Office applications and other computer applications required. Experience with EPIC highly preferred and ability to learn new technologies, web tools, and basic design tools is imperative Knowledge of ambulatory care nursing principles or experience in an outpatient setting preferredMust have reliable transportation and valid Ohio driver's licenseSALARY: $58,700-$73,300OTHER INFORMATION:Background and reference checks will be conducted. In accordance with Equitas Health's Drug-Free Workplace Policy, pre-employment drug testing will be administered. Hours may vary, including working some evenings and weekends based on workload. Individuals are not considered applicants until they have been asked to visit for an interview and at that time complete an application for employment. Completing the application does not guarantee employment. EOE/AAORGANIZATION INFORMATION:Established in 1984, Equitas Health is a regional not-for-profit community-based healthcare system and federally qualified community health center look-alike. Its expanded mission has made it one of the nation's largest HIV/AIDS, lesbian, gay, bisexual, transgender, and queer/questioning (LGBTQ+) healthcare organizations. With 22 offices in 12 cities, it serves more than 67,000 individuals in Ohio, Kentucky, and West Virginia each year through its diverse healthcare and social service delivery system focused around: primary and specialized medical care, retail pharmacy, dental, behavioral health, HIV/STI prevention, advocacy, and community health initiatives.Equitas Health requires employees to be fully vaccinated for COVID-19 as defined by the CDC, subject to applicable, verified accommodation requests.The Equitas Health Pharmacy operates as a social enterprise for Equitas Health; 100% of profits are reinvested back into the organization's programs and services. For more information, visit equitashealth.com or find them on Facebook or Twitter.