Population Health Coordinator

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Position Title:                   Population Health Coordinator

General Description:

The Population Health Coordinator (PHC) is responsible for coordinating multiple aspects of care/data for patients with other members of the Quality Team and Care Teams to reach mutual goals for quality of care and patient safety.

Using population health reports and registries, the PHC will identify patients who are not meeting specific quality measures and patients who are out of care/out of range for disease prevention or management indicators. The PHC will work with care teams to ensure care gaps are closed and/or correctly captured in the Electronic Medical Record. The PHC works to improve the overall care of patients through sustained workflow improvement and correct utilization of data entry. Focus will be determined based on project grant funding and health center need (e.g., Colorectal Cancer, Cervical Cancer, Breast Cancer, Eye Care, Prenatal Care). This position is the population health liaison between care teams, specialist offices, patients, scheduling/referrals departments, and labs.

This position requires compliance with Caring Health Center’s compliance standards, including its Standards of Conduct, Compliance Program, and policies and procedures. Such compliance will be an element considered as part of regular performance evaluation.

Reports to:                           Director of Quality Assurance and Improvement

Salary/Status:                      Non-Exempt

Hours:                                     40 Hours/Week


Minimum Requirements:

  • Associate’s or Bachelor’s degree in health-related field or equivalent background and work experience.
  • Patient-focused experience or customer service background.
  • Working knowledge or familiarity with electronic health records and other health care IT systems desirable.
  • Proficient in data management and reporting.
  • Ability to practice discretion and comply with strict state, federal, and internal policies when handling confidential patient medical information.
  • Problem-solver with ability to multi-task.
  • Desire to work as part of an interdisciplinary team to improve patient’s health and wellness.
  • Ability to sensitively engage diverse groups of patients regarding their participation in their healthcare.
  • Polished interpersonal skills.
  • Comfortable working as member of multidisciplinary, collaborative teams.
  • Flexible and able to recognize and adapt to changing circumstances as they arise.
  • Think creatively and devise innovative solutions.
  • Highly organized, self-directed, and able to accomplish daily workflows in central office and practice-based settings.
  • Well-developed analytic and writing skills.
  • Proficiency in MS Word, Excel, Access and PowerPoint.
  • Spanish language fluency strongly desirable.
  • Experience with rapid-cycle improvement a plus, but not required.

Principle Responsibilities and Duties:

  • Learn and understand primary care practice workflows with respect to optimal and coordinated health care for target patient populations.
  • Generate reports to identify patients who have care caps or missing data related to quality measures or disease prevention/management.
  • Utilize patient registries and reports to facilitate preventive screenings and support utilization of chronic disease treatments by tracking clinical outcomes and medical histories, ensuring correct data entry in Electronic Medical Records, and obtaining data to fill gaps in patient records. Data focus will be determined based on project grant funding (e.g., Colorectal Cancer, Cervical Cancer, Breast Cancer, Eye Care, Prenatal Care).
  • Navigate external data systems to research or obtain needed data.
  • In collaboration with Electronic Medical Records, Care Coordination, Clinical, Quality, and Project Management teams, manage recall system and standard outreach calendar for bulk mailing and proactive outreach.
  • Task patient outreach to appropriate staff (e.g., Medical Assistants, Nurses, Community Health Workers, Care Coordinators) and ensure patients are contacted for the purpose of achieving established outreach goals. When needed, contact patients for outreach.
  • Provide data support to practice staff in the development of creative processes to proactively manage target populations.
  • Support Referrals, Care coordination, and Clinical teams in ensuring all referral loops for disease prevention and management are closed (e.g., Colorectal, Cervical Cancer, Breast Cancer, Eye Care, Prenatal Care)
  • Support data entry/sharing to external partners/funders as needed.
  • Utilize motivational interviewing skills as necessary to remove barriers to care and engage patients.
  • Contribute to quality improvement and process design of population health efforts.
  • Recognize and report data inconsistencies to appropriate personnel.
  • Communicate and collaborate with Medical Assistants, Nurses, Community Health Workers, and Care Coordinators, and Providers to optimize patient care.
  • Work closely with practice teams planning tests of change. Participate in the planning, implementation, and analysis of quality improvement cycles as appropriate.
  • Assist in the validation of patient panels for target populations.

Working Conditions:

  • This position requires the ability to use a computer workstation, viewing a CRT.
Location: Springfield, MA
Apply for this Position Job code: 1000075
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