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At Promise Healthcare, our mission is to improve the health and well-being of the diverse communities we serve by providing high-quality, equitable healthcare to people of all ages. Our vision is to be a catalyst for positive change, shaping a future where healthcare is not a privilege but a fundamental right for every person and no one is left behind.

Be a part of a team that values excellence, equity, and community. If you're ready to lead with passion and precision, apply now to become our Perinatal & Population Health Care Coordinator and help us make a lasting impact on the future of healthcare.

The Perinatal & Population Health Care Coordinator supports maternal, infant, and population health outcomes through proactive care coordination, patient outreach, and quality improvement initiatives. This position tracks confirmed pregnancies, monitors and encourages timely prenatal entry, frequent follow up per guidelines, and healthy birth outcomes while monitoring mom and baby through age 2 for successful completion of milestone visits, and performs and tracks outreach to close care gaps across patient populations to improve patient care, quality, and increase payer incentives. Works collaboratively with providers, care teams, and community partners to improve patient engagement and care coordination to advance Promise Healthcare's (PHC) quality of care goals. Supports interdepartmental grant initiatives.

ESSENTIAL DUTIES & RESPONSIBILITIES:

Perinatal & Maternal Health Coordination:

• Identify and track all patients with confirmed pregnancies in NextGen electronic health record (EHR) and separate log to report data on patients kept and patients transferred.
• Schedule prenatal history visit to complete ACOG template prior to first prenatal visit with primary care provider (PCP).
• Conduct proactive outreach to ensure timely perinatal visits and consistent follow-up per guidelines, maintain log of interactions and outcomes.
• Monitor and record prenatal program measures per established workflows: UDS early entry into care and birth weight.
• Work with internal and external partners to connect patients to wraparound services (WIC/CUPHD, enrollment, behavioral health, dental, community resources, etc.).
• Coordinate care and conduct outreach for newborns and children through age 2, ensuring completion of required immunizations, developmental screenings, preventative services, and timely follow-up for identified care gaps.

Population Health & Quality Improvement:

• Participate in population assessment and risk stratification to identify high-risk and priority patient groups for patient outreach.
• Use population health tools, EHR data, and payer gap reports to identify, prioritize, and address care gaps for assigned patient populations.
• Support UDS, HEDIS, and Pay-for-Performance (P4P) initiatives by scheduling and tracking visits for screening, preventive care, and chronic disease management.
• Apply quality improvement methods (SMART goals, PDSA cycles, root cause analysis) to refine workflows and improve outcomes.
• Conduct patient outreach and document all patient interactions and outcomes, in the EHR and separately as needed, ensuring data accuracy and integrity.

Community & System Integration:

• Refer to integrated care to screen patients for social drivers of health (SDOH) and connect them to appropriate community programs (transportation, housing, etc.).
• Maintain updated knowledge of available community resources and support referral coordination and enrollment/enabling services.
• Foster partnerships with local organizations to expand available resources and reduce service gaps and duplication.
• Promote patient engagement and shared decision-making through education, patient portal support, and care planning.
• Advocate for patients to ensure equitable access to medical and supportive services.

Other Responsibilities:

• Support intern program by providing mentorship and training to align with department goals.
• Assist with patient engagement activities, such as portal enrollment, informational events, and satisfaction surveys.
• Participate in staff meetings, training sessions, and interdisciplinary care team discussions as assigned.
• Support Promise Healthcare's mission, vision, values, and quality improvement plan.
• Perform other related duties as assigned.

QUALIFICATIONS:

• Strong organizational skills, attention to detail, and ability to manage multiple priorities.
• Must deliver outstanding customer service and communicate with patients, colleagues, and other stakeholders with courtesy, professionalism, and respect.
• Ability to think critically, work independently, and collaborate across teams.
• Must exhibit cultural sensitivity and be accustomed to and comfortable with working in an inclusive environment and with a diverse patient population.
• Ability to foster collaborative relationships with clinical leaders and staff, payers, and external partners.
• Possess initiative, flexibility, and the ability to follow organizational protocols.
• Ability to adapt to changing work environment and duties as needed/assigned.

EDUCATION / EXPERIENCE REQUIREMENTS:

• High school diploma or equivalent required; bachelor's degree in social work, public health, nursing, or related field preferred.
• Minimum one year of experience in a Federally Qualified Health Center (FQHC) or community health setting preferred.
• Prior experience in patient care, case management, quality improvement, or population health strongly preferred.
• Proficiency in NextGen EHR preferred.
• Minimum basic proficiency in Microsoft Excel and other computer applications with the ability to maintain patient tracking logs, manage data accurately, and communicate information effectively to leadership and care teams required.

AMAZING BENEFITS:

• Medical
• Dental
• Vision
• 401k with employer match
• FSA
• Vacation
• Sick Leave

We are an Equal Opportunity Employer and do not discriminate against any employee or applicant for employment because of race, color, sex, age, national origin, religion, sexual orientation, gender identity, status as a veteran, and basis of disability or any other federal, state or local protected class.

Completed background check and drug screen required prior to start date.