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Clinical Care Coordinator (Population Health)

  • Requisition no: 526972
  • Work type: Full Time
  • Location: Other NYC Locations
  • School/Department: Faculty Practice Organization
  • Grade: Grade 106
  • Categories: Health/Clinical, General Administration
  • Job Type: Officer of Administration
  • Bargaining Unit:
  • Regular/Temporary: Regular
  • End Date if Temporary:
  • Hours Per Week: 35
  • Salary Range:

Position Summary

Working in collaboration with the population health team, the Clinical Care Coordinator (Population Health) is responsible for coordinating and integrating high-quality, cost-effective care delivered to patients across an episode of illness or throughout the entire continuum of health care delivery.  The Clinical Care Coordinator (Population Health) will adopt ColumbiaDoctors’ care coordination process and workflow to achieve improved health outcomes for populations.


Care Management – 50%

  • Develop detailed care plans for patients based on the assessment of patient's condition, clinical needs, social support and barriers
  • Act as a liaison between patients, caregivers, and health care and social services to improve overall health and social outcomes
  • Document in patients' medical records and other data systems to ensure effective data collection and evaluation according to ColumbiaDoctor’s Care Coordination and Management Standards
  • Conduct comprehensive post-discharge assessments for hospitalized patients and provide interventions to reduce complications and readmissions
  • Provide education on disease process, medications, and self-management methods to patients and/or their caregivers with high clinical acuity and in consideration of barriers to care
  • Outreach to patients who frequent the Emergency Room for avoidable visits, provide additional self-management support and educate them on alternatives such as same-day physician appointments and urgent care facilities

Operations – 20%

  • Support programs and/or initiatives with the goal of reducing complications and/or readmissions for the designated patient population
  • Perform chart reviews at all assigned sites/practices to identify and close gaps in care as needed.  Including but not limited to communication of findings to providers
  • Increase overall compliance with medical appointments and routine screenings and improve medication adherence
  • As part of the population health team, utilize data and tools to implement initiatives to achieve the reduction of inappropriate utilization of services such as avoidable ER visits, duplicate tests or procedures, risk identification, and decrease avoidable readmission rates
  • Contribute to preventative health and chronic disease outcome improvement interventions such as newsletter articles, CAP IPA member education, and outreach, surveys, etc.
  • Performs all other duties and participates in debriefing and quality improvement initiatives as directed

Strategy – 20%

  • Ensures care management programs are aligned with unit strategy and framework: improving the patient’s experience of care (including quality and satisfaction), improving the health of populations, and reducing costs as appropriate.
  • Collaborates with internal and external teams to develop plans and strategies to improve population health (e.g. close gaps in care, decrease healthcare costs, and improve the patient experience). 
  • Utilize tools and strategies for effective communication including informal and formal presentations for internal and external audiences.

People  - 5%

  • Promotes staff professionalism and performance with coaching, training, and feedback.  Mentors others in individual and team accountability, modeling behavior, and demonstrating best practices/techniques. Demonstrates self-development and keeps current on a variety of clinical management and health care topics.

Compliance – 5%

  • Keeps current on all organizational, regulatory compliance, and patient privacy trainings policies (e.g. infection control, public safety, EH&S, HIPAA, OSHA, etc.) and successfully completes all required trainings.
  • Maintain a safe and secure work environment by following all OSHA, EH&S, and public safety policies and guidelines.
  • Ensure that Medical Center, Service Corp, and Department policies and procedures are followed.

Minimum Qualifications

  • Bachelor's Degree or combination of education and experience.
  • Unrestricted New York State license to practice as a registered nurse or nurse practitioner.
  • A minimum of 5 years of related experience.
  • An equivalent combination of education and experience may be considered.
  • Ability to work with all stakeholders: physicians, office staff, practice managers, executive suite, consultants, payor organizations, etc.  
  • The candidate must be well organized and be able to manage a demanding workload and complex cases in an accurate and timely.
  • Demonstrated advanced skills in problem assessment, resolution, and collaborative problem-solving in complex, and interdisciplinary settings including advanced proficiency in healthcare administration.
  • Ability to communicate effectively in both oral and written form.  This position requires the ability to interact positively, constructively, and effectively with patients, professional staff, providers, and organizational stakeholders. 
  • Ability to travel within the 5 boroughs of NYC and Westchester County.
  • Ability to work independently and follow through and handle multiple tasks simultaneously.
  • Ability to work collaboratively with a culturally diverse staff and patient/family population demonstrating tact and sensitivity in stressful situations.
  • Advanced proficiency in Microsoft Office (Word & Excel) or similar software is required and an ability and willingness to learn new systems and programs.
  • Must be a motivated individual with a positive mindset and exceptional work ethic.
  • Must successfully pass system requirements.

Preferred Qualifications

  • BSN preferred.
  • Strong proficiency in population health, utilization review/utilization management, and/or quality improvement.
  • Demonstrated strong proficiency in project management skills including planning and executing technical and operational project activities with cross-functional teams.
  • Experience with EPIC is preferred.
  • Experience with HEDIS, QARR, Quality Payment Program/MIPS, PCMH.
  • Spanish language proficiency is preferred.
  • Experience and knowledge of managed care plan operations.    


Patient Facing Competencies

Minimum Proficiency Level

Accountability & Self-Management

Level 3 - Intermediate

Adaptability to Change & Learning Agility

Level 3 - Intermediate


Level 3 - Intermediate

Customer Service & Patient-Centered

Level 3 - Intermediate

Emotional Intelligence

Level 3 - Intermediate

Problem Solving & Decision Making

Level 3 - Intermediate

Productivity & Time Management

Level 3 - Intermediate

Teamwork & Collaboration

Level 3 - Intermediate

Quality, Patient & Workplace Safety

Level 3 - Intermediate

Leadership Competencies

Minimum Proficiency Level

Business Acumen & Vision Driver

Level 1 -Introductory

Performance Management

Level 2 - Basic

Innovation & Organizational Development

Level 1 -Introductory

Equal Opportunity Employer / Disability / Veteran

Columbia University is committed to the hiring of qualified local residents.

Applications open: Eastern Daylight Time
Applications close:

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