Population Health Specialist

FETTER HEALTH CARE NETWORK INC•North Charleston, SC

10h

About The Position

Manage an assigned patient caseload and collaborate with patients, providers, and practice teams to assess patient needs and support overall wellbeing. Develop, implement, and evaluate population health, quality, and practice transformation strategies. Coordinate outreach and enrollment programs that identify underserved population segments, help them access services, and support the delivery of quality care to the communities served.

Requirements

Bachelor's degree or higher in Public Health, Healthcare Administration, or Human Services preferred.
Minimum of two years of experience working in population health, quality improvement, or a related field preferred.
Ability to travel extensively within assigned communities.

Responsibilities

Participate, as directed, in screening new clinic service requests according to agency-approved procedures and applicable Board policies and procedures.
Complete, review, and assess patient data to help validate that HEDIS guidelines have been met, and promote awareness of screenings and healthy lifestyles.
Provide ongoing support based on identified problems, needs, and service-plan strategies to help patients achieve their goals and objectives.
Conduct regular face-to-face reviews with patients and/or relevant staff to assess progress and modify service plans as needed.
Participate in interagency planning and service coordination to improve continuity and effectiveness of patient services, including provider referrals and follow-up calls for referral no-shows.
Coordinate outreach events with FHCN partners and other entities for target patient populations, including migrant and seasonal agricultural workers and people experiencing homelessness.
Partner with School-Based Clinics to optimize care for students and coordinate appropriate follow-up care.
Monitor, track, and close gaps in patient health care reports to optimize care.
Assist with community events, collaborate with internal teams, help patients schedule provider appointments, and promote awareness of screenings and services that support healthy lifestyles.
Partner with organizations to verify accurate patient data reporting.
Follow HIPAA guidelines and regulations, maintain patient confidentiality, and document information in a timely manner.
Securely access, document, transmit, and maintain patient medical records using electronic software.
Provide guidance and counsel regarding social service needs, including insurance eligibility, ACA, SC Thrive, Access Health, food banks, and prescription assistance.
Apply population health and Triple Aim concepts and appropriate quality improvement methodologies, such as Model for Improvement, Lean, and PDSA, to support population health and quality improvement performance.
Collaborate with FHCN partners on population health, quality improvement, and health system innovation strategies and initiatives.
Perform other duties as assigned.