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 Drivers 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. MINIMUM REQUIREMENTS - Education: Bachelor’s degree required. Equivalent combination of education and experience may be considered in lieu of degree. Experience: 1 year relevant experience. Licensure: None.