Population Health Coordinator

MD at Home

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You'll elevate health equity and improve outcomes for complex patients through home-based care coordination.

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Full-time

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Remote (for Latin America residents)

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about 1 month ago

We’re seeking a Population Health Coordinator to support our home-based primary care team. This role is ideal for healthcare-trained professionals who are passionate about patient communication, care coordination, and improving outcomes for medically complex patients.Key ResponsibilitiesServe as the primary clinical contact for an assigned patient panelManage patient cases within the EMR (AthenaHealth preferred)Conduct monthly chronic care follow-ups and symptom assessmentsEvaluate patient concerns and determine appropriate next stepsCoordinate urgent visits, provider appointments, and referralsTrack medications, lab results, and outstanding care needsEducate patients on care plans, refills, and condition managementCollaborate closely with providers to support quality care standardsAssist in meeting and exceeding Medicare quality metrics📍 Remote – LATAM-based candidates only🕘 Monday–Friday | 8:00 AM–5:00 PM (OT as needed)

About MD at Home:

MD at Home is a pioneer in the Home-Based Primary Care space rendering care to patients with acute or chronic medical conditions with difficulty accessing office-based practitioners. Our mission is to improve the community’s health equity and eliminate health disparity. MD at Home utilizes data analytics and takes a population health management approach to ensure higher quality standards delivered throughout the community. Our holistic approach allows us to bring to the table a complete multi-disciplinary team of providers such as dietitians, optometrists, pain specialists and DME suppliers as well as laboratory and imaging services to the patient’s homes. With our population management approach, we continue to bend the cost curve, reduce patient acuity and reduce overall all-cause facility admission and readmission.

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www.md-athome.com/

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