Patient Care Coordinator - Community Health Worker (CHW)

Job Description

Job Description

Description:

Patient Care Coordinator – Community Health Worker (CHW)

Gunnison Valley Hospital is creating a new position focused on helping patients stay connected to their healthcare team and better manage their health.

The Patient Care Coordinator – Community Health Worker will work directly with patients and providers to coordinate care, follow up with patients between visits, help manage Chronic Care Management (CCM) and Remote Patient Monitoring (RPM) programs, connect patients with community resources, and support quality and population-health initiatives.

Strong Medial background however you don't need experience with CCM, RPM, MIPS, or Community Health Worker programs to apply — we are looking for the right person and will provide training.

This could be a great opportunity for someone with experience as a Medical Assistant, LPN, CNA, clinic employee, care coordinator, Community Health Worker, or other healthcare professional who:

• Is ready to help build a new program
• Enjoys working with and helping patients
• Is compassionate and a good communicator
• Is highly organized and dependable
• Is comfortable learning new technology
• Enjoys problem-solving and following through
• Wants to help patients better navigate their healthcare
• Is interested in improving healthcare in our rural communities
• Willing to complete Community Health Worker (CHW) certificate with in six months of hire

Bilingual English/Spanish skills are a plus.

This is an opportunity to help GVH build a new program that connects patients, providers, technology, and community resources to improve the health of the people we serve.

Come help us build the future of connected care at Gunnison Valley Hospital.

Position can close at anytime

Requirements:

POSITION SUMMARY

The Connected Care Coordinator – Community Health Worker supports Gunnison Valley Hospital's Chronic Care Management (CCM), Remote Patient Monitoring (RPM), MIPS/quality, and community health initiatives. This position works closely with patients, providers, clinic staff, and community partners to coordinate care, support patients with chronic conditions, identify barriers to care, and connect patients with needed healthcare and community resources.

ESSENTIAL DUTIES

CCM & Care Coordination

· Maintain and coordinate an assigned panel of CCM patients and conduct regular patient outreach and follow-up.

· Assist patients with care plans, appointments, referrals, and follow-up needs.

· Identify barriers to care and connect patients with appropriate GVH and community resources.

· Assist with follow-up after hospitalizations and emergency department visits.

· Communicate patient concerns or changes in condition to the appropriate nurse or provider and accurately document care-management activities.

Remote Patient Monitoring (RPM)

· Assist with enrolling and educating patients in GVH's RPM program and help with basic device setup/troubleshooting.

· Monitor assigned RPM dashboards and patient worklists.

· Follow up regarding missing or concerning readings and follow established protocols for escalating clinical concerns.

· Document RPM activities and patient communication.

MIPS, Quality & Population Health

· Support MIPS, population health, and quality-improvement activities.

· Identify patients with gaps in care and assist with outreach and follow-up.

· Track screenings, testing, appointments, and other quality measures.

· Maintain reports, worklists, spreadsheets, and dashboards and work with clinic staff to improve quality performance.

Community Health

· Help patients navigate healthcare and community services.

· Connect patients with transportation, food, financial, behavioral health, and other available resources.

· Build relationships with community organizations and participate in outreach and patient education as assigned.

QUALIFICATIONS

Required

· High school diploma or equivalent.

· Strong communication, organization, and computer skills.

· Ability to work independently, manage multiple priorities, and communicate compassionately with patients and families.

· Willingness to complete Community Health Worker training and certification as required by GVH.

Preferred

· Medical Assistant (MA), Licensed Practical Nurse (LPN), Community Health Worker, or related healthcare experience.

· Experience in primary care, chronic disease management, care coordination, population health, CCM, RPM, MIPS, or quality improvement.

· Experience with electronic health records and healthcare technology.

· Bilingual English/Spanish.

KNOWLEDGE & SKILLS

· Compassionate, patient-focused, highly organized, and detail-oriented.

· Comfortable using computers, EHRs, spreadsheets, dashboards, and other technology.

· Able to manage a patient panel, prioritize responsibilities, and communicate effectively with providers and clinical staff.

· Able to recognize concerns and appropriately escalate them to a nurse or provider.

· Interested in chronic disease management and improving rural healthcare.

SCOPE OF ROLE

The Connected Care Coordinator works as part of the patient's healthcare team and follows established GVH protocols and the individual's professional scope of practice. The Coordinator does not independently diagnose medical conditions, change medications, or make treatment decisions. Clinical concerns are referred to the appropriate licensed nurse or provider.

OUR GOAL

Provide patients with a consistent point of contact who helps them manage chronic conditions, stay connected to their care team, successfully participate in remote monitoring, and access the healthcare and community resources they need.