The Population Health Coordinator (PHM) assesses the educational needs of our patient population and their families, as well as planning, implements, and evaluating effective methods to accommodate their needs. Consistent with the needs documented by the continuous quality improvement (CQI) data, the PHM creates and implements health intervention programs to improve the health status of the patients served by VIP. The position also involves developing and organizing educational materials for the clinic staff, and clients, and coordinating community outreach, which includes educational seminars, workshops, and tabling activities. Additionally, this position involves traveling, the (PHS) must be willing to travel to and from various sites within four of the five boroughs as assigned by his/ her supervisor to provide and support telehealth services.

POSITION QUALIFICATIONS:

Essential Functions Include and are Not Limited to:

Enabling Services

• Administer the Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences (PRAPARE) for the purposes of accurately identifying the patient's/clients need and providing appropriate internal and external referrals for services.
• Liaise with VIP’s health services, mental and substance recovery program directors, and community partner organizations to assure patients/clients are connected and receive services identified during the intake process.
• Assess individual patients' needs, and recommends appropriate health education resources/services.
• Responds to questions relating to health issues, providing relevant information and/or referring the person to the appropriate source.

Health Literacy

• Provide timely and targeted health education to patients, family, and caregivers via waiting room presentations, over the phone, and via videoconference.
• Develop health literacy content with input from mental and substance recovery program directors.
• Additionally, the HLC will administer the PHQ-9 and other health and well-being assessments for the purposes of tailoring individual health education and materials.

Telehealth

• Provide technical assistance to patients, family, and caregivers on how to navigate VIP’s Telehealth platform for their virtual medical visits.
• Liaise between VIP staff (clinicians, providers, and support services) and the patients before and during their virtual appointments.

• Provide ongoing training to staff on any updates on the telehealth process and its procedures.
• Assist the departments during telehealth appointments to navigate clients and staff to appropriate virtual rooms.
• Call patients to confirm and get consent for telehealth visits prior to their appointments.
• Coordinate with office staff the clinician’s and providers’ schedules for those patients that will be seen via telehealth.

Patient Engagement and Community

• Always provide excellent customer service to all patients, families, and caregivers.
• Maintain dynamic caseload to achieve the best outcomes for VIP patients.
• Conduct basic presentations (non-clinical) on health topics, enabling and telehealth resources.
• Participate in health fairs, neighborhood community activities, screenings, and special events.

Reporting

• Maintain patient charts and all necessary data entry in a timely manner.
• Maintain comprehensive documentation for data collection, and provide statistical data and/or reports per grant requirements.
• Provide additional support to VIP staff to conduct chart reviews for patients with care gaps.

Other duties

• Participate in meetings and activities as required.
• Performs additional duties as assigned by supervisor.

EDUCATION AND EXPERIENCE:

• Bachelor’s Degree required in Health Education and Health Promotion, Community Health, or Public Health
• CHES certification preferred
• Prior experience or training in health education or Public Health
• Prior experience in developing, implementing, and evaluating programs
• Prior experience in creating interventions for chronic illness

SPECIAL SKILLS AND KNOWLEDGE:

In addition to the above-listed job responsibilities and educational requirements, the ideal candidate for this position possesses most or all the following:

• Strong organizational skills: able to manage diverse responsibilities and provide services at various sites.
• Ability to establish and maintain effective working relationships with colleagues, clients, and contracted providers of health care services.
• Ability to plan, organize, implement, and evaluate programs which include conducting needs assessments; creating action plans; and performing professional development activities.
• Strong problem-solving skills and ability to address issues professionally and effectively.
• Excellent oral and written communication skills needed to provide counseling to clients, document casework, and provide training.

Ability to work both independently and within a team environment