Population Health Coordinator

Under the supervision of the Manager of Population Health & ACO Performance the Population Health Coordinator (PHC) supports the organizations efforts to improve the health of the patient population through patient outreach and engagement in care and data capture improvement efforts.

Responsibilities

The Population Health Coordinator plays a key role in the Health Centers Quality Improvement efforts by routinely collaborating with Quality team members Medical Assistants (MAs) Nurses Providers and Operations staff to track care close patient care gaps and maintain accurate data in the EHR. Key duties include:

Data Capture and Improvement Efforts:

• Leverages available information and reports from the current Epic electronic health record (EHR) the legacy EHR (Athena Practice) and population health platforms including Arcadia to locate missing patient care gap data and outside results. Examples include and are not limited to colonoscopies diabetic retinal exams mammograms and external lab results (HbA1c Cologuard PAP smears/HPV testing)
• Accurately records care gap data and external results into the Epic EHR to ensure structured data is captured for quality measure reporting.
• Appropriately updates Health Maintenance Care gaps based on care gap data located
• Documents patient exclusions from care gaps as appropriate within the EHR and through any payer-specific exclusion workflows.

Patient Outreach and Engagement in Closing Care gaps

• Initiates outreach to patients via reminder letter telephone call secure text message or MyChart message to schedule appointments and remind patients about overdue care including procedures lab tests and appointments related to quality metrics or annual wellness visits.
• Works with patients to obtain outside records of care that address care gaps and enters data as appropriate into the EHR.
• Addresses patient replies to outreach campaigns appropriately and in a timely manner.
• Utilizes motivational interviewing skills as necessary to appropriately engage patients directing and receiving support from the clinical care team(s) when necessary
• Documents outreach and other notes in the EHR and other databases to document outreach and to communicate to clinical and teams information about care that is due for individual patients
• Engage patients in conversation to uncover challenges they face in accessing services (i.e. transportation housing instability financial hardship language barriers) and collaborate with care teams to connect patients with resources.

Supports ongoing reporting for program oversight and management:

• Tracks outreach efforts and audit activities and provides summary progress reports to leadership
• Coordinates with specialties and primary care to remind team members of open care gaps.
• Generates and distributes patient registry reports as needed.
• Conducts chart audits for data validation and to identify opportunities for improvement.
• Conducts chart audits for referrals test tracking and lab/imaging tracking and implements protocols to administratively close the loop for tracking as appropriate
• Adheres to all agency and departmental policies and procedures
• Upholds the principles of customer service in all interactions with all co-workers patients and external stakeholders
• Participates in additional quality improvement activities elevating patient stories and trends that highlight gaps in care delivery or access
• Adheres to the highest principles of patient and client confidentiality
• Adheres to established safety policies procedures and precautions; identifies potential or actual unsafe situations in the environment and informs appropriate staff
• Attends all required meetings in-services and professional training
• Performs related duties as required

• Strong Electronic Medical Record skills including medical terminology and understanding of clinical quality data
• Highly organized and self-motivated individuals with the ability to work autonomously
• Well-developed analytic and writing skills required
• Ability to work harmoniously and effectively with colleagues patients clients and vendors across the spectrum of diversity including but not limited to race ethnicity color gender identity sexual orientation age socio-economic status national origin and immigrant status religious or spiritual identity disability (physical mental emotional and developmental) veteran status and/or limited English proficiency.
• Willingness to contribute towards Fenways efforts in becoming an anti-racist organization and promoting a culture dedicated to ongoing development in service of humility equity diversity inclusion and belonging where differences are acknowledged and valued.
• Proficient in MS Word Excel and PowerPoint.
• High school diploma or GED
• At least 2 years of relevant experience in healthcare

Preferred Qualifications:

• Epic medical record experience
• Clinical training/background
• Training in motivational interviewing
• Working knowledge or familiarity with electronic health records and other health care IT systems
• Working knowledge of clinical quality metrics such as HEDIS NCQA or UDS metrics
• Patient-focused experience or customer service background
• Fluent in Spanish
• Bachelors degree