PCMH Coordinator

PCMH Coordinator Medicos Medical Center Position Summary Medicos Medical Center is seeking a highly organized and patient-focused PCMH Coordinator to support our Patient-Centered Medical Home (PCMH) program. The PCMH Coordinator will lead care coordination efforts, monitor quality measures, support population health initiatives, and help ensure compliance with NCQA and TennCare PCMH standards. Key Responsibilities Track and report quality metrics and PCMH performance measures. Coordinate patient referrals, transitions of care, and post-hospital follow-up. Identify high-risk patients and address gaps in preventive and chronic care services. Facilitate daily care team huddles and quality improvement activities. Develop and monitor patient care plans. Educate patients on self-management goals and available community resources. Support

NCQA PCMH

recognition and TennCare value-based initiatives. Collaborate with providers, staff, specialists, and community partners to improve patient outcomes. Spearhead data collection and track performance metrics required to maintain PCMH recognition and earn TennCare value-based incentive payments. Act as a central point of contact between providers, specialists, and the patient to ensure smooth care transitions, manage referrals, and follow up on post-hospital discharge. Analyze patient panel data to identify high-risk patients and close gaps in preventive care, screenings, and chronic disease management (e.g., diabetes or hypertension). Lead regular care team huddles to review individual patient needs and ensure clinical and administrative staff work together efficiently. Empower patients and their families to understand their medical conditions, set self-management goals, and connect them with local community resources. Qualifications Associate's or Bachelor's degree in Healthcare Administration, Nursing, Public Health, Social Work, or related field preferred. Minimum 2 years of experience in healthcare, care coordination, case management, quality improvement, or population health. Knowledge of

PCMH, NCQA

standards, and value-based care models preferred. Experience using Electronic Health Records (EHR) systems. Strong organizational, analytical, and strategic planning skills, with the ability to manage multiple initiatives, interpret quality and population health data, identify improvement opportunities, and implement action plans to achieve organizational goals. Ability to work effectively with diverse patient populations. Excellent written and verbal communication skills, with the ability to communicate effectively with patients, providers, staff, and external stakeholders. Demonstrated ability to actively listen, follow management directives, adapt to changing priorities, and incorporate feedback to support organizational goals and continuous improvement initiatives. Skills Care coordination and population health management Quality improvement and data analysis/reporting Patient education and engagement Team collaboration and communication Problem-solving and critical thinking Microsoft Office Suite and EHR systems Time management and multitasking Strong customer service skills Organizational and strategic planning skills Ability to follow directives, adapt to priorities, and incorporate feedback for continuous improvement Excellent written and verbal communication skills

Pay:

$17.00 - $25.00 per hour

Work Location:

In person