Population Health Advocate

First Choice Community Healthcare•Albuquerque, NM

2d•Hybrid

About The Position

The Population Health Advocate plays a crucial role in improving patient care and health outcomes. This position involves reviewing patient data to identify care gaps, communicating with patients and staff to ensure these gaps are addressed, and tracking quality measure data. The advocate will analyze data in collaboration with care teams, present findings, and assist with care coordination. They will also provide patients with information on community resources and medication assistance, and implement population health activities. Additionally, the role includes conducting pre-visit chart reviews, assisting patients with scheduling and necessary tests, and performing patient outreach to improve compliance and outcomes. The advocate will support patients in following their care plans, encourage self-management, and facilitate access to community resources. Other duties as assigned are also part of this role.

Requirements

Minimum of two (2) years’ recent experience in a healthcare setting required.
Current medical assistant or equivalent experience.
Experience and knowledge of electronic health records required.
Knowledge of medical terminology, CPT and ICD-10 codes required.
Ability to communicate effectively and maintain cooperative relationships with providers, staff members, patients, and the medical community.
Ability to employ tact, diplomacy, and compassion with all types of people.
Must successfully function in a fast-paced, service-oriented environment.
Must have strong organizational skills, be detail-oriented, a self-starter, possess ability to set priorities, and function as part of a team.
Possess ability to use good judgment, maintaining confidentiality at all times.
Possess and maintain computer skills to include working knowledge of Word, Outlook, Excel, and the ability to learn other software as needed.
Working knowledge of and ability to implement appropriate standing orders and care management practices.
Strong interpersonal, resource development, research and communication skills and the ability to work as an effective team member with a wide range of medical and administrative staff and outside entities, as well as a diverse patient population.
Ability to communicate complex information in a manner easily understood by diverse listeners and strong customer service skills.
Ability to speak clearly and concisely.
Ability to read, understand, provide, and follow verbal and written instruction.
Ability to establish and maintain effective working relationships with patients, employees, community partners, and the public.
Ability to function independently/autonomously while maintaining effective and necessary communication with Director.
Knowledge and familiarity with compliance programs, cooperate fully and comply with laws and regulations, including HIPAA.

Nice To Haves

Strong research and analysis skills highly preferred.
Experience with data analytics and quality metrics preferred.
Knowledge of community resources preferred.
Bilingual English/Spanish is highly preferred.

Responsibilities

Reviews patient registries and other data sets to identify gaps in care, disease specific screenings, and basic preventative health screens.
Communicates with patient and/or clinic staff, to ensure timely closure of identified gaps.
Documents activities/interventions within patient charts or other reporting formats, as appropriate.
Collects and tracks monthly, quarterly, and annual process improvement/quality measure data.
Conducts analysis of data in collaboration with a variety of care teams to assist in identification of improvement activities.
Presents data collected in an organized format to facilitate analysis and identification of improvement opportunities.
Accesses daily reports to identify patients hospitalized, discharged, and treated in the Emergency Department (ED).
Provides assistance with care coordination, facilitates communication between patients, caregivers, and providers, helps to addresses barriers to care, and promotes optimal allocation of resources.
Provides information to patients and families regarding community resources, medication assistance, and other healthcare needs.
Implement/assist with a variety of healthcare quality improvement/population health activities, as indicated and directed.
Participate in the development, implementation and/or evaluation of FCCH PCMH initiatives.
Conduct patient chart reviews for pre-visit planning using standard protocols to enhance visit efficiency and effectiveness.
Assists patients with scheduling, ordering lab work, and/or testing that may be needed for a chronic disease as defined in the organizational standard protocols.
Participate in patient outreach (via phone, virtual platform, clinic, and/or home visit) to achieve greater patient compliance with appropriate treatment plans, standards of care/protocols and improved patient healthcare outcomes.
Supports patients in an effort to make them successful while following the written plan of care, as indicated in the discharge plans and ambulatory care plan.
Encourages patients to use self-management tools as provided.
Facilitate patients’ access to available community support, educational and/or other healthcare resources, as appropriate to their needs and according to any requirements of health insurance or healthcare financial assistance programs they may (or may not) have.
Other duties, as assigned and/or needed.