Population Health Coordinator

Metropolitan Pediatrics•Portland, OR

11d

About The Position

The Population Health Coordinator proactively tracks patient care needs and helps ensure patients receive services that support their health and well-being. The role oversees and promotes quality improvement related to care processes and payer metrics, including patient engagement, closing care gaps, maintaining accurate patient panels, coordinating with health plans, and combining data sources to provide an accurate picture of population-level care quality. The coordinator leads population management by monitoring and sharing quality data, championing proactive care for the full patient population, and serving as the subject matter expert on organizational quality metrics. The position works with clinic medical home teams, managers, providers, clinical champions, health plans, patients, and families to improve care outcomes, meet quality goals, and support payment programs. It also provides workflow training, participates in meetings and clinic initiatives, and maintains confidentiality of sensitive patient information.

Requirements

College degree or equivalent required.
At least 3 years of experience in a clinical or public health setting.
Experience with electronic medical records (EMR) required.
Understanding of PCPCH (Patient-Centered Primary Care Home) requirements.
Knowledge and understanding of medical terminology and clinical procedures.
At least 3 years of experience in customer service, computers, general office procedures, multitasking, and understanding insurance terms.

Nice To Haves

Master's degree in public health or another clinically related field.
Experience with panel management and quality metrics.
Experience with EPIC.

Responsibilities

Lead population management by monitoring and sharing patient and population quality data to facilitate improved care outcomes.
Champion proactive care for the full population of patients connected with Metropolitan Pediatrics, including patients who do not come in for visits.
Serve as the subject matter expert on the quality metrics for which the organization is accountable.
Participate as an active member of clinic medical home teams.
Support and lead quality improvement activities by applying knowledge of QI methodologies, organizational relationships, goals, and benchmarks.
Proactively contact patients and families identified as needing health maintenance or other care, individually or through automated programs and workflows.
Conduct routine outreach by phone and through scheduled or unscheduled face-to-face meetings before, during, and after appointments, and direct PAS outreach activities to close care gaps and meet goals.
Identify and reduce barriers that interfere with patients' access to health care.
Maintain the provider panel section of the clinic database.
Partner with clinical champions to provide timely and accurate data for quality improvement efforts.
Support monthly partial capitation and quality payment programs by maintaining accurate provider panel lists, onboarding newly assigned patients promptly, and working with health plans and families to correct patient assignments.
Escalate concerns identified through regular tracking to help maintain metric, capitation, and quality payment performance.
Maintain confidentiality of sensitive patient information.
Participate in site-specific and clinic-wide initiatives.
Provide workflow training to staff as needed regarding population health and metric goals.
Attend and actively participate in huddles and team meetings.
Maintain high standards of office conduct and work effectively with others in a team setting.
Maintain punctual, regular, timely, and dependable attendance.
Work effectively in a fast-paced, changing environment while managing time, multitasking, and prioritizing workload.