Base Pay:

$22.00 - $ 32.50 / hour

Job Summary:

Under the direction of the QI Manager, the Wellness Care Coordinator works as part of a multidisciplinary team to support quality patient care, population health activities, and organizational performance. The Wellness Care Coordinator performs patient outreach, care coordination, and pre-visit planning activities, including annual wellness visit preparation and completion of health risk assessments. This role conducts outreach by phone, text, and mail; provides patient education related to preventive and chronic care needs; and facilitates coordination with internal departments and external partners. The Wellness Care Coordinator supports SCHC quality initiatives, including but not limited to Aledade ACO and other programs as assigned by the QI Manager and/or Director of Quality Improvement.

JOB DUTIES AND RESPONSIBILITIES

Patient Scheduling

• Schedules Annual Wellness Visits and coordinates related pre-visit processes to ensure efficient patient flow and readiness for care.
• Assists with coordinating and scheduling other patient appointments as appropriate to support continuity of care and population health activities.
• Reviews and completes Health Risk Assessments, including medical, surgical, and family history, fall risk, activities of daily living, social history, and patient-provider relationships.
• Collaborates with front office and clinical staff to optimize appointment availability and ensure alignment with provider workflow.

Outreach & Care Coordination Conducts patient outreach via phone, text, or mail to support preventive care, chronic disease management, and care gap closure. Provides patient education related to preventive screenings, chronic disease management, and general health maintenance. Assists patients in connecting with appropriate services and resources to support continuity of care and improved health outcomes. Quality Program Support Supports SCHC quality health measures, including but not limited to Aledade ACO and other programs as assigned by the QI Manager or QI Director. Collaborates with clinical teams, Training, Operations, and external partners such as the Aledade ACO team to advance quality initiatives. Assists with implementation and monitoring of workflows tied to quality-related activities, including Annual Wellness Visit optimization, Emergency Department follow-up calls, and transitional care processes. Participates in special projects and operational tasks assigned by the QI Director or QI Manager. Phones

• Answers and routes incoming calls appropriately, maintaining professionalism and appropriate boundaries related to clinical advice and triage.
• Provides clear communication to patients regarding outreach, scheduling, and Health Risk Assessment processes.
• Ensures timely, accurate messaging and follow-up using appropriate communication tools. Health Information Services Duties
• Maintains and protects patient confidentiality of medical reco.

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