Care Coordinator-Population Health

Essen Health Care is the largest privately held, multispecialty medical group in New York, providing high-quality, compassionate care to some of the state’s most vulnerable and underserved residents.

Founded in 1999, we’ve grown from a single primary care office into a network of 50+ locations offering urgent care, primary care and specialty services, from women’s health to endocrinology and psychiatry. We also provide nursing home support, care management, and in-home care through our Essen House Calls program. Guided by a Population Health model, our team of 500+ providers deliver care in-person, at home, or via telehealth, ensuring patients get the support they need when and where they need it.

We’re looking for talented, motivated individuals to join our growing team. Whether you’re a medical provider, administrator, or operations professional, there’s a career here for you. Join us in making a real difference in the health of our community.

Cirrus Health is a healthcare organization working in partnership with Essen Health Care to expand access to coordinated, high-quality, patient-centered care. Through this
collaboration, Cirrus Health supports population health and value-based care initiatives designed to improve patient outcomes, strengthen care coordination, and ensure patients
receive the preventive and ongoing care they need.

Cirrus Health is seeking a Part-Time Care Coordinator to support our Population Health
initiatives, with a primary focus on Gaps in Care, patient outreach, quality measures,
and care coordination.

The Care Coordinator will work closely with healthcare providers, Office Managers, clinical teams, and population health leadership across Cirrus Health locations to identify and
address outstanding care needs. This individual will play an important role in improving quality outcomes, increasing patient engagement, and supporting organizational value based care goals.
The ideal candidate is organized, patient-focused, comfortable working with healthcare data and electronic medical records, and experienced in conducting patient outreach.

• Review patient populations and reports to identify Gaps in Care and outstanding
preventive or chronic care needs.
• Conduct proactive patient outreach by phone and other approved communication
methods to encourage completion of recommended screenings, appointments,
testing, and follow-up care.
• Assist patients with scheduling appointments and navigating appropriate
healthcare services.
• Track outreach attempts, patient responses, appointments, and gap-closure
activities within the appropriate systems.
• Partner with providers and Office Managers to develop strategies for addressing
outstanding quality and care gaps.
• Support initiatives related to preventive care, chronic disease management, annual
wellness visits, screenings, vaccinations, and other applicable quality measures.
• Review patient records to confirm completion of services and ensure appropriate
documentation is available for quality reporting.
• Help identify barriers preventing patients from completing recommended care and
coordinate with the appropriate team members to address those barriers.
• Monitor assigned quality metrics and patient lists and provide updates regarding
outreach and gap-closure progress.
• Support value-based care and population health initiatives, including efforts
focused on improving quality performance and patient outcomes.
• Maintain accurate and timely documentation while protecting patient
confidentiality and complying with HIPAA requirements.
• Collaborate with providers, clinical staff, Office Managers, and Population Health
teams across multiple Cirrus locations.
• Perform additional population health and care coordination responsibilities as
assigned.

High school diploma or equivalent required; associate or bachelor's degree in
healthcare, public health, health administration, or a related field preferred.
• Previous experience in care coordination, population health, patient outreach,
medical office operations, quality improvement, or healthcare administration
preferred.
• Experience working with Gaps in Care and healthcare quality measures strongly
preferred.
• Familiarity with value-based care, preventive health measures, HEDIS, or similar
quality programs is a plus.
• Experience using an Electronic Health Record (EHR/EMR) system; eClinicalWorks
(eCW) experience is a plus.
• Strong communication and patient engagement skills.
• Ability to communicate effectively with patients, providers, Office Managers, and
clinical teams.
• Strong organizational skills and attention to detail.
• Ability to manage patient lists, follow-up activities, and multiple priorities
independently.
• Comfortable working with reports, spreadsheets, and healthcare data.
• Knowledge of HIPAA and patient confidentiality requirements.
Preferred Skills
• Population Health and/or Value-Based Care experience
• Gaps in Care management
• Patient outreach and engagement
• HEDIS/quality measure knowledge
• eClinicalWorks (eCW)
• Care coordination
• Preventive care outreach
• Quality improvement
• Healthcare data tracking and reporting
• Strong follow-through and documentation skills
Schedule

This is a part-time position. The Care Coordinator will support Population Health activities
and collaborate with Cirrus Health providers and Office Managers based on organizational
and patient needs.

Essen Health care is proud to be an equal opportunity employer, and we seek candidates who desire to work in and serve an ethnically diverse population.