Population Health Specialist
About The Position
The Population Health Specialist is responsible for outreach to patients with gaps in chronic disease management and preventive care. This role serves to support health status improvement through access to services, education, wellness support and reinforcing the importance of the patient/primary care provider relationship. Essential Functions Utilizes the Medical Home model to provide targeted outreach to identified patients. Includes current and new patients. Utilizes EMR Systems, registries, health maintenance data, opportunity reports, payer portals and other data as available to validate gaps and conduct outreach activities as assigned. Maintains tracking of outreach and gap closure. Using EMR tools, initiates outreach via EMR portal messages, phone calls, and/or via letters. Updates EMR Systems and payer portals as appropriate. Supports supplemental data submission process for plans without electronic supplemental feeds. Collaborates with Practice Transformation Team on the identification of quality care improvements. Shares findings of identified concerns/issues/quality care improvements related to gap closure, ordering process and documentation of care with quality team so that they may be addressed and/or implemented efficiently and effectively. Prepares reports as needed. Collaborates with practice staff to provide additional information and coordination of practice level phone calls. Performs special focused projects/audits as assigned. Complete all scheduled eye exams at ambulatory clinics, updating portal information, and ensure practices receive results for all patients. Traveling to ambulatory sites. Investigation of community resources/assistance needed for patient population; ensure an agency guest and/or information is available monthly to support the development of the material provided to the clinics. Outreach to outside clinics and health systems for results and quality data needed for improvement of practice scores. Perform quarterly quality measure audits to ensure practices compliance with documentation requirements.
Requirements
- High School Diploma or equivalent
- 2 years of relevant experience
- Minimum of 2 years of experience as a medical assistant in a clinical physician practice, a clinical nursing program, or 2+ years of in a population health related role.
- Experience in data entry.
Nice To Haves
- Completion of an accredited Medical Assistant program or LPN, EMT, ER Tech, or equivalent of education and relevant experience.
- CRT-Medical Assistant, Certified (CCMA) - NHA National Health career Association Upon Hire
Responsibilities
- Utilizes the Medical Home model to provide targeted outreach to identified patients. Includes current and new patients.
- Utilizes EMR Systems, registries, health maintenance data, opportunity reports, payer portals and other data as available to validate gaps and conduct outreach activities as assigned.
- Maintains tracking of outreach and gap closure.
- Using EMR tools, initiates outreach via EMR portal messages, phone calls, and/or via letters.
- Updates EMR Systems and payer portals as appropriate.
- Supports supplemental data submission process for plans without electronic supplemental feeds.
- Collaborates with Practice Transformation Team on the identification of quality care improvements.
- Shares findings of identified concerns/issues/quality care improvements related to gap closure, ordering process and documentation of care with quality team so that they may be addressed and/or implemented efficiently and effectively.
- Prepares reports as needed.
- Collaborates with practice staff to provide additional information and coordination of practice level phone calls.
- Performs special focused projects/audits as assigned.
- Complete all scheduled eye exams at ambulatory clinics, updating portal information, and ensure practices receive results for all patients.
- Traveling to ambulatory sites.
- Investigation of community resources/assistance needed for patient population; ensure an agency guest and/or information is available monthly to support the development of the material provided to the clinics.
- Outreach to outside clinics and health systems for results and quality data needed for improvement of practice scores.
- Perform quarterly quality measure audits to ensure practices compliance with documentation requirements.
Benefits
- Comprehensive benefits package to meet your financial, health, and work/life balance goals.
- On-demand pay program powered by Payactiv
- Discounts directory with deals on the things that matter to you, like restaurants, phone plans, spas, and more!
- Optional identity theft protection, home and auto insurance, pet insurance
- Traditional and Roth retirement options with service contribution and match savings
- Eligibility for benefits is determined by employment type and status
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
High school or GED
Number of Employees
5,001-10,000 employees
