Population Health Coordinator - Medical Focus

At Groups, the Population Health Coordinator will play a key role in supporting the delivery of high-quality care to select high-acuity member populations, as well as members in select transitional periods of their recovery journey. Each coordinator will specialize in one of these focus areas:

• Medical Focus: Pregnant and postpartum members
• Recently hospitalized members and/or those with complex medical care-coordination needs
• Members struggling with polysubstance use
• Members at highest risk of precipitated withdrawal

Within their area of focus, the coordinator supports quality care-delivery and improvement through registry review, interdisciplinary collaboration, documentation, and direct member-facing care (group and individual). This role is pivotal in pioneering innovative care methods at Groups, grounded in the Collaborative Care Model. The ideal candidate is flexible, confident engaging across disciplines and regions, and comfortable navigating ambiguity, with a passion for leading and participating in pilot projects to drive continuous improvement in patient care.

Responsibilities

Data and Registry Management / Collaborative Care Model Support

• Maintain an accurate registry of members enrolled in dedicated special populations or care pathways
• Use the registry to assess progress, track outcomes, and prioritize daily tasks for yourself and the care team
• Facilitate registry reviews with counselors, medical providers, consulting specialists, etc.
• Participate in caseload consultation and communicate treatment recommendations to the care team
• Use the registry to assess care quality and propose population-level quality improvement initiatives

Care Coordination

• Perform and document internal and external care coordination tasks for the most complex members or scenarios
• Assist in training staff on the Collaborative Care Model (registry review, asynchronous consultations, concise presentations)

Direct Member Care

• Support individual needs of members on an assigned caseload via telephonic and SMS outreach, and telemedicine encounters
• Perform screenings, structured assessments, brief therapeutic interventions, and care coordination with community providers
• Provide member education about co-occurring mental health, physical health, and substance abuse disorders and treatment options
• In partnership with peer support and care navigation, provide transitional care support to high-acuity members, including interdisciplinary meetings, orientation groups, care coordination, and 1:1 support
• Facilitate and document treatment plan changes with clinical and medical providers
• Escalate urgent/crisis situations to appropriate leadership and support follow-up and safety planning

Pilot Support and Project Management

• Provide administrative, technical, and leadership support on pilot projects as delegated by medical, clinical, and operational leaders

Duties Specific to Medical Focus

• Support medication management as prescribed by medical providers, focusing on treatment adherence, side effects, and effectiveness
• Assist in creating and delivering low-barrier, literacy- and culturally-appropriate educational materials for members, providers, and co-prescribers
• Review medical data and prepare documentation to support efficient, top-of-license medical care
• Support medical-related coordination of care

While this position may have a primary focus in one area (Medical, Mental Health, or Social Care), team members are expected to contribute across focus areas as needed to best support members and ensure comprehensive care.

Qualifications

Knowledge, Skills and Abilities

• Strong understanding of care coordination and case management
• Knowledge of health care regulations and HIPAA compliance
• Excellent communication skills with the ability to manage communications across a large, dispersed team and represent the organization externally
• Proficient in facilitating communication across telehealth, virtual platforms, telephone, and in-person settings
• Willingness to work in/out of the office, acquire additional training, and adjust schedule hours to accommodate member care (early or evening within usual work week)
• Exceptional ability to maintain focus, prioritize tasks, and adapt to rapid organizational changes
• Problem-solving and decision-making abilities to navigate complex care situations
• Capacity to build trust and rapport with diverse patient populations
• Proficiency with multiple EMRs, Microsoft Office/Google Suite (spreadsheet proficiency required), and other computer-based documentation tools
• Excellent organizational and documentation skills
• Ability to analyze data and outcomes
• Ability to use discretion and work independently under general supervision
• Understanding of and adherence to the Professional Code of Conduct

Requirements

• Registered Nurse (RN) or (Maine Only) Licensed Practical Nurse (LPN) who completes the SAMHSA required training for an X-DEA license
• Bachelor's degree in Nursing preferred
• At least 5 years experience providing direct patient-care in addiction medicine or related behavioral health areas at high-quality, reputable organizations
• For remote roles: access to reliable internet (50M download / 10M upload or higher) and strong WiFi signal
• Must meet pre-employment requirements and maintain state and job-related guidelines for background screening (may include fingerprinting, drug testing, health screening, CPR/Basic First Aid, and license/credential verifications)

Pay

$75,000 - $90,000

Schedule

Monday - Friday, 8am - 5pm EST