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US Heart and Vascular is needing a Remote Population Health Coordinator to join our team

Position Summary

The Population Health Coordinator is a key member of the Virtual Value-Based Care (VBC) team, responsible for coordinating Remote Patient Monitoring (RPM) workflows, managing patient referrals, and supporting care delivery across multiple practices. This fully remote role focuses on patient outreach, enrollment coordination, workflow management, and ensuring timely progression of patients through RPM and other VBC programs.

The Population Health Coordinator partners closely with RNs, providers, clinic staff, and operations leadership to ensure patients receive timely, efficient, and coordinated care. This role directly supports Value-Based Care initiatives by improving patient engagement, supporting compliance, and driving operational efficiency.

Responsibilities & Duties

• Reviews and manages RPM and VBC program referrals daily.
• Initiates patient outreach within established timelines (24–48 hours).
• Educates patients on program services and obtains/verifies consent.
• Documents all outreach attempts and outcomes in the EMR.
• Ensures referrals are progressed through workflow stages in a timely manner.
• Coordinates patient enrollment into RPM, PCM, TCM, and other VBC programs.
• Tracks device orders, shipments, and activation status.
• Assists patients with onboarding, troubleshooting, and general program questions.
• Monitors enrollment pipeline to ensure no delays or gaps in patient progression.
• Maintains accurate tracking of assigned patient panels.
• Serves as a liaison between patients, RNs, providers, and internal teams.
• Escalates clinical concerns or abnormal findings to RN staff appropriately.
• Collaborates with team members to ensure continuity of care.
• Supports onboarding and training of new team members as needed.
• Ensures all patient interactions are documented accurately and in real-time.
• Maintains compliance with CMS and organizational documentation requirements.
• Supports billing readiness by ensuring proper documentation of outreach and engagement.
• Participates in audits and quality reviews as needed.
• Maintains a safe workplace by following established safety protocols, reporting hazards, and participating in required safety training. 
• Fosters a team-oriented environment by encouraging cooperation, providing support, and resolving conflicts constructively. 
• Demonstrates integrity, professionalism, and respect in all interactions. 
• Follows processes and policies for the organization. 
• Reports to work as scheduled, ready to perform duties, and promptly notifies their supervisor of any attendance issues 
• Adapts to changing priorities, processes, and business needs. 
• Performs other duties as assigned. 

Knowledge, Skills, and Abilities Required

• Knowledge of federal, state, and local laws, statutes, regulations, codes, and standards related to the area of responsibility.
• Knowledge of the principles, concepts, and theories relevant to the assigned functional area.
• Knowledge of EMR systems, with eClinicalWorks preferred.
• Working knowledge of Office 365 programs such as Excel, Outlook, Word, PowerPoint, etc.
• Working knowledge of EMR systems.
• Skill in completing assignments accurately and with attention to detail.
• Skill in strong communication and patient engagement.
• Skill in organization and effective time management.
• Ability to communicate clearly and concisely both orally and in writing in English, to various audiences.
• Ability to manage time, organize work, set priorities, meet deadlines, and follow up on work assignments with minimal supervision.
• Ability to work independently, and as a team, to complete daily activities according to the work schedule.
• Ability to manage multiple priorities in a fast-paced, remote work environment.
• Ability to maintain accuracy, compliance, and attention to detail in all work activities.
• Ability to work independently while collaborating effectively across teams.
• Ability to support and uphold the Mission, Vision, and Values of USHV and its practices.

Minimum Qualifications

• One (1) year of experience in a healthcare setting
• Experience with patient outreach, referrals, or care coordination.
• Experience working in EMR systems.

Preferred Qualifications

• Certified or Registered Medical Assistant is welcomed but not required
• Experience with Remote Patient Monitoring (RPM), PCM, CCM, or TCM programs.
• Experience in Value-Based Care or population health initiatives.
• Experience working in a remote or virtual care environment.