Population Health Coordinator

Greater Lawrence Family Health Center•Methuen, MA

About The Position

Established in 1980, the Greater Lawrence Family Health Center (GLFHC) is a multi-site mission-driven non-profit organization employing over 700 staff whose primary focus is providing the highest quality patient care to residents throughout the Merrimack Valley. Nationally recognized as a leader in community medicine (family practice, pediatrics, internal medicine, and geriatrics), GLFHC has clinical sites throughout the service area and is the sponsoring organization for the Lawrence Family Medicine Residency program. GLFHC is currently seeking a Population Health Coordinator (PHC) to join our care management team. The Population Health Coordinator (PHC) plays a key role in the health center’s overall quality, risk adjustment, team-based care, and Accountable Care Organization (ACO) performance. The PHC will support multiple PCMH teams and under the direction of the PCMH team lead or delegate, they will provide data coordination, and outreach for patient populations with chronic illnesses and preventive health screenings. The PHC will support PCMH teams in organizing and optimizing pre-visit huddles, post care follow-up and proactive patient outreach as directed. This role will close care gaps by reviewing patient medical data and helping to schedule appointments and screenings that are overdue - and working with PCMH practice teams and Clinician leadership. The PHC is an integral member of the Population Health program and helps support the integrated care team promote optimal coordination of care for patients. The PHC builds relationships with patient in order to assist the primary care team in developing an effective and accessible plan of care and ultimately tracks adherence to this plan of care. Supports team based pre-visit planning activities and coordinates follow-up and loop closure Under the leadership of the AVP of Clinical Integration and Director of Population health, the PHC collaborates with Quality Improvement and ACO team members to help meet annual quality and risk adjustment goals Utilize online data management systems such as data warehouse and Arcadia to collaborate with Data Analyst to create patient registries, validate patients’ empanelment to our health center, and identify/resolve patient quality and coding gaps Based on patient registries, track patients due for preventive care, chronic disease management, follow-up of abnormal results, or other health care services to identify gaps in care Ensure timely and accurate documentation of outreach or other relevant information in the EHR Review registries of patient ED and hospital visits and coordinate with nursing team to ensure appropriate follow-up appointments are in place Communicate with care teams and other relevant staff to provide updates and get input on outreach, quality/coding initiatives as needed to help ensure quality and coding gaps are addressed Work closely with ACO Performance Improvement team and other ACO and health center staff to monitor and to optimize quality of care, clinical workflows, and accurate capturing of quality/coding data

Requirements

Must have 3 years’ experience as a senior medical assistant and 5 years of experience in a clinical setting
Bilingual (English / Spanish) required. Must be able to read and write english
Demonstrable experience working in primary care practice support/quality management roles
Self-motivated and self-directed to work within a team and/or work independently
Strong analytical, problem solving, planning and prioritization skills
Excellent interpersonal skills required
Excellent verbal and written communication skills required
Basic working knowledge of Excel

Nice To Haves

1-2 years of greater working in primary care, clinic, population health role
Experience working in managed care highly desirable

Responsibilities

Support PCMH teams in organizing and optimizing pre-visit huddles, post care follow-up and proactive patient outreach as directed.
Close care gaps by reviewing patient medical data and helping to schedule appointments and screenings that are overdue - and working with PCMH practice teams and Clinician leadership.
Support the integrated care team promote optimal coordination of care for patients.
Builds relationships with patient in order to assist the primary care team in developing an effective and accessible plan of care and ultimately tracks adherence to this plan of care.
Supports team based pre-visit planning activities and coordinates follow-up and loop closure
Collaborates with Quality Improvement and ACO team members to help meet annual quality and risk adjustment goals
Utilize online data management systems such as data warehouse and Arcadia to collaborate with Data Analyst to create patient registries, validate patients’ empanelment to our health center, and identify/resolve patient quality and coding gaps
Based on patient registries, track patients due for preventive care, chronic disease management, follow-up of abnormal results, or other health care services to identify gaps in care
Ensure timely and accurate documentation of outreach or other relevant information in the EHR
Review registries of patient ED and hospital visits and coordinate with nursing team to ensure appropriate follow-up appointments are in place
Communicate with care teams and other relevant staff to provide updates and get input on outreach, quality/coding initiatives as needed to help ensure quality and coding gaps are addressed
Work closely with ACO Performance Improvement team and other ACO and health center staff to monitor and to optimize quality of care, clinical workflows, and accurate capturing of quality/coding data