Population Health and Transitions of Care Coordinator – Primary Care Full Time

*Previous experience in care coordination, transitions of care, and population health is required for this position.*

Company Description

HealthHelper partners with healthcare practices nationwide, utilizing a combination of data, AI automation, and people to support efficient, high-quality patient communication and care coordination, while off-loading tasks from overworked providers and practice staff. HealthHelper works behind the scenes, offering healthcare organizations solutions for inbound overflow call management, schedule optimization, care gap closure, transitions of care, and referral management.  

Opportunity

Join our mission-driven team to help primary care practices support patients! This dual role plays a critical part in helping primary care patients access preventive care services, and in supporting patients recently discharged from the hospital or emergency department.

Position Title – Population Health and Transitions of Care Coordinator

Reports To – Director of Operations

Location – This is a remote, work-from-home position, candidates in the Eastern/Central Time Zones are preferred

Works in Collaboration With

Director of Operations, Chief Medical Officer, Chief Product Officer, Team Leads, and peers internally, as well as customer office staff – primarily Practice Administrators, Nurse Care Managers, and Medical Assistants at partner primary care practices.

Position Summary

The Population Health and Transitions of Care Coordinator manages both automated and manual outreach campaigns to engage and schedule patients for preventive services, important screenings, primary care visits, and post hospital follow ups. This position is responsible for ensuring patients are contacted promptly, scheduled for services within the appropriate time-frame, and that any clinical or social barriers to care are identified and escalated appropriately.

This role offers growth potential, including opportunities to evolve into a Team Lead position. The Coordinator will also help refine our outreach processes and gather feedback from patients and customers to continuously improve our transitions of care programs.

Responsibilities

• Monitor care gap and quality metric lists to guide and initiate patient outreach campaigns for care gap closure
• Monitor daily hospital and ED discharge lists and initiate patient outreach campaigns within required timeframes
• Conduct automated and manual outbound call/text campaigns to patients 
• Conduct assessments on patients recently discharged from inpatient stays or ED visits to review discharge instructions, confirm medication understanding, and assess follow-up needs
• Schedule timely primary care/specialty follow-up appointments, screenings, and preventive services 
• Identify and escalate patient clinical or logistical issues (e.g., medication confusion, transportation barriers) to the appropriate care team members
• Work in multiple EHRs (Electronic Health Records) and population health systems to manage care gaps and transitions of care
• Document outreach outcomes accurately in both internal databases and customer EHRs
• Respond to inbound patient or practice inquiries related to care gap closure or post-discharge care
• Participate in quality improvement initiatives related to quality metrics, ED utilization, hospital readmission reduction, and care continuity
• Collaborate with leadership to improve workflows, outreach messaging, and overall program effectiveness

Required Experience

• Population Health Management (REQUIRED): Experience helping patients access preventive and diagnostic care – examples – Population Health Manager or Patient Outreach Coordinator for a population health program
• Transitions of Care or Care Coordination (REQUIRED): Experience supporting patients after hospital or ED discharge – examples – Transitions of Care Coordinator, Case Manager, or Navigator Role
• Primary Care Practices: Experience working within (preferred) or alongside primary care practices to coordinate follow-up care and close communication loops with providers
• Technology: Comfort using EHR systems, communication technologies, population health tools, care management platforms, and other healthcare technology tools

Nice-to-Have Skills

• Strong attention to detail and task follow-through
• Ability to prioritize and manage high-volume and varied workloads
• Clear and professional written communication
• Ability to follow structured clinical protocols
• Experience working remotely and independently
• Bi-lingual English and Spanish (Strongly preferred)