Pediatric Population Health Case Manager

$22 - $35/Yr

State of Virginia - Charlottesville, VA

Full-time - Entry Level

Charlottesville, VA

Executive, Legislative, and Other General Government Support

About the position

The Pediatric Population Case Manager plays a key role in supporting Pediatric Primary Care at UVA Health. This position is dedicated to enhancing care coordination for medically complex cases and addressing Social Drivers of Health (SDOH). By facilitating seamless transitions, adherence support, and resource connection, the role ensures patients and families receive comprehensive, patient-centered care. Operating within Population Health, the position integrates innovative tools and workflows, supports value-based care initiatives, and collaborates with primary care providers to improve health outcomes.

Responsibilities

• Review pediatric patient medical records to identify healthcare needs and gaps in care using data insights from the Fortify platform integrated with EPIC.
• Assist with scheduling and rescheduling appointments for pediatric patients and families.
• Facilitate ER-to-outpatient transitions, ensuring mental health and other priority patients are seen within expected timelines.
• Document care coordination efforts in patient medical records.
• Conduct standardized screenings, including Social Drivers of Health (SDOH), and follow through with closed-loop referrals to address healthcare barriers.
• Coordinate referrals and follow-ups for services, such as community resources, durable medical equipment (DME), and home health services.
• Collaborate with Pediatric Primary Care and Population Health teams to streamline workflows and improve healthcare access using registry-driven insights.
• Support care navigation under value-based payment initiatives, aligning with Fortify's contracts while ensuring broad applicability across UVA Health.
• Collaborate with Fortify's operations to utilize registry-driven data for improving pediatric care without duplicating efforts.
• Support families in understanding discharge instructions and care plans.
• Conduct regular follow-up calls with patients and families to address concerns and ensure adherence to care plans.
• Leverage data from Fortify registries, including Wellness, Asthma, and Epilepsy, to provide personalized care and close gaps in services.
• Connect patients and families with financial assistance programs and other supportive resources.
• Act as a liaison between Population Health and external agencies to ensure continuity and consistency in patient care.
• Participate in training and development opportunities to maintain knowledge of innovative IT tools and best practices in pediatric population health.
• In addition to the above job responsibilities, other duties may be assigned.

Requirements

• Bachelor's Degree preferred. In lieu of degree, 1-3 years of relevant experience may be considered.
• 1 year of experience in a clinical environment is preferred.
• Licensure: None.