Population Health Coordinator

Alexander Valley Healthcare•Cloverdale, CA

18h

About The Position

This role focuses on Program Management, Outreach Management, and Data Management within a population health context. The Population Health Coordinator will maintain an understanding of various funders' quality improvement program measures and specifications, critically review data for shifts or trends, and report findings. Responsibilities include continuous monitoring of QI measures, identifying areas for improvement in data quality and clinical performance, and providing training and support to staff. The role involves reviewing patient charts, uploading missing data, and updating quality dashboards. Additionally, the coordinator will engage patients in their preventive care, generate contact lists, monitor patient panels, and schedule annual wellness and preventive care visits. They will utilize technologies like Relevant and Luma Health for patient communication, develop and execute an annual recall plan to maximize preventive care services, and ensure high continuity in patient appointment scheduling. The role also includes downloading membership rosters, reaching out to new patients, and generating population health patient lists. Data management involves assisting the Quality Department with data population and report preparation for QA/QI activities, proactively validating data quality, collaborating with clinical staff during audits, and cleaning up eCW patient chart data to identify care gaps. Other responsibilities include participating in committees, attending trainings, and working on special projects.

Requirements

Ability to read, write, and communicate in the English language.
Experience with project management and coordinating programs required.
Ability to communicate effectively with diverse patients and their family members.
Ability to read and analyze patient charts, analytic procedures, and governmental regulations.
Ability to perform basic math calculations using fractions, percentages, and ratios.
Knowledge of MS Office, especially Excel: copying and pasting data, summarizing data, applying filters, sorting, and data analysis functions such as pivot tables.
Ability to comply with state and federal confidentiality laws, including HIPAA.
Ability to work unsupervised and as part of a team.
Cheerful and positive demeanor.
Refrains from participation in gossip, dysfunctional group interactions, and divisive behavior.
Displays courteous and professional behavior in all interactions with the public.
Works cooperatively with other staff members.
Displays flexibility in accepting, changing, or carrying out assignments.
Adheres to dress code expectations, including fragrance-free requirements.
Displays sensitivity in a multicultural environment.
Ability to maintain staffing and organizational confidentiality.

Nice To Haves

Bilingual in Spanish is strongly preferred.
One year of clinical, health education, counseling, or health-related program experience preferred.
Experience with eClinicalWorks (eCW) and Relevant analytics preferred.
Bachelor’s degree in a health care or related field preferred.

Responsibilities

Maintain a current understanding of various funders’ quality improvement program measures and specifications such as HRSA’s Uniform Data System (UDS), Partnership HealthPlan’s Quality Incentive Program, Aliados’ Performance Improvement Program, and other programs offered by commercial insurers.
Critically review the data for shifts or trends and report them to the Chief Quality Officer. Activities include continuous monitoring of identified QI measures, identification of areas of data quality, and clinical performance in need of improvement, and training/support of involved staff members.
Review charts of patient quality measure populations and upload missing lab results, diagnostic imaging results and patient visits to ensure complete data sets.
Check quality scores monthly (at a minimum) and update dashboards accordingly.
Engage patients on their whole person preventive care by generating contact lists and monitoring both panels and scheduling of annual wellness and preventive care visits per the Recall Protocol.
Utilize appropriate technologies such as Relevant and Luma Health to create and send automated, HIPAA-compliant messages to patients.
Perform an annual recall plan that maximizes the preventive care services AVH provides to its patients, with a goal of 95% recall of patients due year to year.
Maximize provider capacity to AVH standard while maintaining high continuity in scheduling patient appointments with their primary care providers with a continuity goal of 95%.
Download membership rosters from insurance plans and outreach to new patients.
Generate population health patient lists and distribute them to responsible staff.
Assist Quality Department staff in populating data and prepare reports needed to demonstrate Quality Assurance/Quality Improvement (QA/QI) activities.
Proactively validate data to ensure quality of data and reports sent from the QI department.
Collaborate with and support providers, managers, supervisors, medical assistants and nurses when audited results fall outside the standard of care.
Work with clinical staff to clean up eCW patient chart data and identify care gaps at the point of care that affect reporting and achieving performance measures.
Participate in the Quality Committee and other committees as needed.
Attend related trainings and conferences.
Work on special projects, as needed.
Other duties as assigned.