Population Health Case Manager

The Population Health Case Manager plays a key role in patient progression at UVA Health. Responsibilities include reviewing patient charts, scheduling appointments, calling patients weekly, conducting screenings, and connecting patients with community resources. This role involves interacting with patients telephonically, collaborating with healthcare teams, emergency room and clinical care teams, and external partners. The position delivers comprehensive care coordination, aiming to enhance patient outcomes and elevate the overall quality of healthcare services. Committed to VDH (Virginia Department of Health) standards, they collaborate with healthcare teams for a patient-centered approach, contributing to holistic and efficient healthcare experiences.

• Review patient medical records.
• Assist with appointment scheduling and rescheduling.
• Document work in the medical record.
• Submit reports on productivity and patient progression.
• Ensure compliance with hospital and department policies.
• Coordinate care with health system team members and care teams in the community.
• Conduct weekly phone calls with patients to review post-discharge plans and address concerns.
• Prepare patients/families for discharge and engage care team.
• Assist Population Health clinicians/social workers with care plans.
• Coordinate with external agencies for service continuity.
• Enhance quality of patient care and identify ongoing support needs.
• Review discharge instructions, ensuring patient understanding.
• Place orders for vital signs monitoring and coordinate with providers.
• Conduct standardized screenings such as SDOH (Social Determinants of Health), PHQ, and Digital Health Literacy
• Assist patients with screening documentation for financial assistance.
• Follow up on referrals for appointments, DME, and home health services.
• In addition to the above job responsibilities, other duties may be assigned.

Position Compensation Range: $22.39 – $35.82 Hourly

MINIMUM REQUIREMENTS

Education: Bachelor’s Degree preferred. In lieu of degree 1-3 years of relevant experience may be considered.

Experience: 1 year of experience in a clinical environment is preferred.

Licensure: None.

** APPLICANTS MUST SUBMIT RESUME WITH APPLICATION **

PHYSICAL DEMANDS
This is primarily a sedentary job involving extensive use of desktop computers. The job does occasionally require traveling some distance to attend meetings, and programs.

The University of Virginia, i ncluding the UVA Health System which represents the UVA Medical Center, Schools of Medicine and Nursing, UVA Physician’s Group and the Claude Moore Health Sciences Library, are fundamentally committed to the diversity of our faculty and staff.  We believe diversity is excellence expressing itself through every person’s perspectives and lived experiences.  We are equal opportunity and affirmative action employers. All qualified applicants will receive consideration for employment without regard to age, color, disability, gender identity or expression, marital status, national or ethnic origin, political affiliation, race, religion, sex (including pregnancy), sexual orientation, veteran status, and family medical or genetic information.