Population Health Coordinator
Population Health Coordinator
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1 Vacancy
Job Description
High school diploma required.Bachelors degree preferred
Minimum of 2 years experience in customer service community health or in a health care setting. Experience in promoting healthcare behavior change is desirable
Proficient in data management and reporting
Proven problemsolver with ability to multitask
Prior use of electronic health records and other health care information systems desirable
Ability to identify problems think creatively and devise innovative solutions.
Strong interpersonal skills
Highly organized proactive and attentive to details
Ability to work as member of a collaborative team
Ability to persuade influence and enlist others support in accomplishing objectives
Ability to work with large data sets with guidance from medically trained individuals
Excellent writing and oral presentation skills.
Spanish and other language fluency desirable
Working knowledge of computer software including MS Access Excel PowerPoint and Word.
Massachusetts GeneralHospital is an Equal Opportunity Employer.
By embracing diverseskills perspectives and ideas we choose to lead. Applicationsfromprotected veterans and individuals with disabilities are stronglyencouraged.
The MGH Community Health Centers are creating a new centralized Population Management system across the MGH Health Centers designed to identify at risk individuals track them over time and improve the care of patients on chronic opioid therapy. Our goal is to adapt a population health approach currently in use in primary care at MGH to monitor our population with chronic medical conditions such as diabetes and hypertension to the population of patients being treated with chronic opioids including Suboxone in the Health Center Adult Medicine and Mental Health Practices. This would be the first time in our system that a stateoftheart Population Management System is applied on a large scale to three populations in our communities who are often marginalized within the medical system: those with chronic pain opioid use disorder and chronic Hepatitis C. If successful we expect that this project will yield significant improvements in our health centers compliance with established standards of care for these groups and reductions in morbidity and mortality associated with chronic opioid therapy including death. As health care delivery evolves from one based on reactive visitbased encounters this population health management program represents a new paradigm where an organized datadriven team proactively seeks to optimize preventive and chronic disease care.
The Population Health Coordinator supports the development of patientcentered teambased care. S/he will support primary care physicians (PCPs) and adult medicine practices in managing their panel of patients using a registry population management informatics tool. By gathering and organizing patient data the Population Health Coordinator works to identify patients unmet needs engage patients in their own care gather summary information for treatment interventions and enhance ongoing communication between the patient and her/his care team. The goal of the PHM program is to facilitate highvalue patientcentered care that improves timely access to and provision of preventive services and substance use diorders treatment.
Develops a keen understanding of health center primary care practice requirements for optimal coordinated population health in substance use disorders
Works as an effective team member of the population health management program and Substance Use Disorders initiative
Manages data collection using a registry prepares reports on findings and provides interpretations and recommendations to each center
Contributes to quality improvement and care redesign of population health efforts
Principle Duties and Responsibilities:
Manage patient registries and provide the members of health care teams in health center practices with the data required to meet the health needs of the practice
Support practice staff to develop creative processes to proactively manage target populations work with SUDS Program Patient Advocates in each of the centers to ensure goals of the program are on track and met.
Provide data management coordination and patient outreach as needed for specific target patient populations (Substance Use Disorders)
Contributes to a positive experience for patients and families through courteous telephone interactions and interview activities accurate and expeditious routing as well as referral to appropriate clinical staff when necessary
Synthesize sort format data and generate adhoc reports. Present data to each of their assigned health center primary care practices
Assist in process mapping and development of workflows for population health management at each of the health center practices.
Recognize and report data inconsistencies to appropriate personnel
Contributes to the teamwork within and between departments. Regularly attends and participates in meetings with coworkers and HC staff. Provides constructive ideas suggestions and feedback in a positive manner. Works collaboratively with coworkers to effectively resolve issues that impact departmental or hospital operations
Perform all job functions in compliance with applicable federal state local company and funder policies and procedures
Other duties as assigned
Quality Improvement and Process Design
Collaborate with care teams to establish populationappropriate previsit and point of care processes
Provide data to the care teams to properly perform these processes
Monitor and correct patient attribution to the practice and the care teams within the health center
Required Experience:
IC
Employment Type
Full-Time
