Job description
POSITION SUMMARY:
Under the supervision of the Administrative Manager, the Population Health Specialist provides programmatic support for the GIM Primary Care Population Health team. The Pop Health Specialist is responsible for coordinating patient outreach for optimal management of preventive care and chronic disease management. The Population Health Specialist will assist in care management for GIM Primary Care patients, coordinating outreach based on identified needs, facilitating access to primary care and other internal and external resources as needed, monitoring patient's progress, and tracking practice performance. The Specialist is responsible for documentation in the electronic medical record and complying with all data entry, data integrity, and data tracking requirements for BMC and funding agencies' contract monitoring reports as required.
Position: Population Health Specialist
Department: Primary Care Clinic - MP
Schedule: Full-Time
ESSENTIAL RESPONSIBILITIES / DUTIES:
Outreach Coordination
Appointment/Visit Support
Meets hospital-wide standards in the following areas:
Other Duties:
(The above statements in this job description are intended to depict the general nature and level of work assigned to the employee(s) in this job. The above is not intended to represent an exhaustive list of accountable duties and responsibilities required)
JOB REQUIREMENTS
EDUCATION:
CERTIFICATES, LICENSES, REGISTRATIONS REQUIRED:
EXPERIENCE:
KNOWLEDGE AND SKILLS:
Req id: 25401
Under the supervision of the Administrative Manager, the Population Health Specialist provides programmatic support for the GIM Primary Care Population Health team. The Pop Health Specialist is responsible for coordinating patient outreach for optimal management of preventive care and chronic disease management. The Population Health Specialist will assist in care management for GIM Primary Care patients, coordinating outreach based on identified needs, facilitating access to primary care and other internal and external resources as needed, monitoring patient's progress, and tracking practice performance. The Specialist is responsible for documentation in the electronic medical record and complying with all data entry, data integrity, and data tracking requirements for BMC and funding agencies' contract monitoring reports as required.
Position: Population Health Specialist
Department: Primary Care Clinic - MP
Schedule: Full-Time
ESSENTIAL RESPONSIBILITIES / DUTIES:
Outreach Coordination
- Supports all Population Health outreach activities by coordinating with GIM clinic staff, the Population Health team and BMC's dedicated outbound call center.
- Creates, updates and manages call scripts and directions for patient outreach campaigns.
- Monitors patients' progress via registry and EMR, following up with patient and primary care provider as necessary.
- Provides outreach to patients via reminder calls and/or letters to ensure preventive care appointments are attended.
- Supports outbound call performance using Interactive SharePoint and Redcap software.
- Conducts patient interviews as needed.
- Exports, manipulates and tracks large datasets for patient outreach. Responsible for list management.
- Updates performance trackers, decision trees and dashboards.
- Proficiently uses data management software including Arcadia and Excel.
- Synthesizes information to determine Quality performance and effectiveness of pilot programs.
- Monitors key performance indicators to gage program effectiveness and adjust processes as necessary.
- Shows initiative to promote collaboration with key stakeholders to push performance forward.
- Uses problem solving skills to identify issues and recommend solutions.
- Produces meeting materials to inform discussion and decision making.
- Supports annual chart abstraction activities for Quality contracts
- Complies with departmental, regulatory and contract requirements for documentation recording, and data collection, and submits department statistics and other records and reports within required time frames.
- Documents patient encounters, resource development efforts, and other interventions for each patient, including date, time, and signature in the electronic medical record.
Appointment/Visit Support
- Prepares population health forms for patients prior to appointment date
- Supports primary care provider during patient visit, accepting warm hand-offs for education or appointment scheduling as needed.
- Assists with scheduling outpatient visits and follow-up appointments as needed
- Provides education and supports patients. Uses a variety of culturally, linguistically and educationally appropriate strategies, in a variety of settings. Coordinates with Interpreter Services, as needed.
- Develops and maintains strong relationships with the community and resources to ensure patient access.
Meets hospital-wide standards in the following areas:
- Conforms to hospital standards of performance and conduct, including those pertaining to patient rights and privacy
- Utilizes hospital's policies and standards as the basis for decision making and to support the hospital's mission and goals.
- Follows established hospital infection control and safety procedures
Other Duties:
- Promotes a positive and collaborative work environment supportive of the hospital's missions and goals.
- Adapts to changing departmental needs, including but not limited to, offering assistance to other team members, adjusting assignments, and other functions as determined by Practice Manager.
- Provides other administrative and special project assistance as required or assigned by Clinic Managers.
- Remains knowledgeable of and follows appropriate policies, procedures, and work standards, including but not limited to, policy regarding hours of work, absenteeism, and tardiness.
- Maintains competency in areas of responsibility to ensure quality of care.
- Maintains strict protocols of all confidential or sensitive information.
- Attends hospital required and relevant training sessions or activities, as assigned.
- Provides a link between the GIM Primary Care and other hospital departments.
- Assists patients by linking them to a broad range of services, including, but not limited to, healthcare support services, social work, GIM resource navigator, specialty department navigators, financial assistance, child-care, housing, food, clothing, transportation, food pantries, and appropriate community resources
- Assists in orientation/training of new staff members and volunteers.
- Performs other duties assigned or as necessary.
- Must adhere to all of BMC's RESPECT behavioral standards.
(The above statements in this job description are intended to depict the general nature and level of work assigned to the employee(s) in this job. The above is not intended to represent an exhaustive list of accountable duties and responsibilities required)
JOB REQUIREMENTS
EDUCATION:
- Bachelor's degree required
CERTIFICATES, LICENSES, REGISTRATIONS REQUIRED:
- None
EXPERIENCE:
- 3-5 years of experience required; preferably related to project management, social work or program development.
KNOWLEDGE AND SKILLS:
- Approaches work with a focus on detail and accuracy
- Demonstrated flexibility with evolving priorities and goals
- Demonstrated critical thinking and problem solving ability.
- Effective verbal, written, and interpersonal communication skills to facilitate interactions with various members of the healthcare team, patients, and their families.
- Ability to understand and interpret complex data analyses
- Ability to work in a fast paced environment, inclusive of organizational skills, critical thinking, and problem solving abilities.
- Bilingual or multi-lingual skills (beyond that of English) appropriate to the patient population served, is preferred.
- Sensitivity to ethnic, cultural, gender, and sexual orientation diversity; values; beliefs; and behaviors.
Req id: 25401
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