Population Management Coordinator

UnitedHealth Group•Auburndale, MA

1d•$20 - $36•Hybrid

About The Position

Explore opportunities with Atrius Health, part of the Optum family of businesses. We’re an innovative health care leader and multi-specialty group practice, delivering an effective, connected system of care for adult and pediatric patients at 28 practice locations in eastern Massachusetts. Our entire team of providers (physicians, PA/NPs and ancillary clinicians) works collaboratively with a value-based philosophy within our group practice as well as with hospitals, rehab and nursing facilities. Be part of our vision to transform care and improve lives by building trust, understanding and shared decision-making with every patient. Join us and discover the meaning behind Caring. Connecting. Growing together. As a member of the clinical care team, is responsible for supporting efforts to meet Atrius quality goals by facilitating both routine preventative care and ongoing chronic disease management for primary care patients. Works in a matrix function with overall direction from clinical and administrative leadership at the IM Service Line and the Performance Excellence department, and daily supervision from clinical and administrative leadership at the IM practice site. Identifies and articulates opportunities for work flow changes to improve quality of care related to the organizational strategic quality goals. Understands complex characteristics of the quality metrics and translates the metrics into actionable workflows for the clinical practice. Serves as the organizer and driver of population management outreach work at the site, and plays a key support role for onboarding patients to the practice. Navigates data for large populations of patients to identify recommended clinical care opportunities and subsequently organizes and prioritizes action items, including allocating tasks to the appropriate member of the care team and ensuring efforts are coordinated and avoid duplication. Manages a high volume of patient outreach for patient populations with chronic illnesses (e.g., diabetes, hypertension and cardiovascular disease) as well as for primary care patients needing preventative screening tests within the broader patient population. 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. Note: The role of Population Management Care Facilitator involves complex and detail-oriented responsibilities, the ability to understand and articulate clinical terms and processes and the ability to interact with patients and clinicians about preventative health and chronic disease management.

Requirements

High School diploma or equivalency certificate (e.g. GED, HiSET, TASC Test) from an accredited institution or governmental unit
Skills and experience typically acquired through 1+ years (one of which is calculated from degree) in a: clinical business support, or clinical research, or ambulatory care setting, or customer service business.
Must reside within New England and be able to attend quarterly on-site meetings at the address above
Driver’s License and access to a reliable transportation

Nice To Haves

Training or experience in population health management
Demonstrated knowledge and understanding of medical terminology
Demonstrated proficiency in Microsoft Office Suite

Responsibilities

Serves as a central organizing point within the site for population management activities. Organizes which patients need calls and coordinates who the appropriate person to make the call would be (typically medical assistants or medical secretaries) in an effort to avoid multiple calls to the same patient
Collaborates with primary care case management, internal and external specialists, nutrition, social work and insurers as needed
Independently review charts, identify or verify care gaps, provide appropriate intervention (e.g. onboarding, outreach, communication to clinician, etc.)
Independently contacts patients, clinical and administrative staff and external organizations to gather and relay clinical and care plan information
Researches individual patient’s clinical information and recommends clinical procedures and tests that are indicated based on standard clinical guidelines
Conducts examinations of the clinical record to determine if outreach for identified ‘care gaps’ is appropriate given patient’s current medical status
As needed, places routine lab orders to assist in ongoing clinical management of patients with chronic diseases
Performs high volume of daily patient outreach calls, mailings and MyHealth messages in regards to lab tests, appointments and other chronic care recommendations made by the primary care team. Documents details of outreach attempts into patients’ electronic medical record to ensure coordination of care
Ensures that all necessary documentation of external medical care is documented into the patient’s Atrius Health electronic medical record
Tracks patient adherence with scheduled appointments, labs, referrals and prescription compliance
Monitors patient adherence to treatment recommendations and works closely with Clinical Pharmacist and Physician to identify cost saving medications for optimal medication compliance to achieve treatment goals
Coordinates and leads monthly chronic disease management panel roster reviews for primary care physicians
Manages information flow of Atrius Health Quality metrics between leadership, clinicians and staff at the site
Conducts regular basic data analyses relevant to site’s specific goals and initiatives
Prepares Excel spreadsheets and PowerPoint slides relevant to site’s performance on quality metrics
Actively involved in practice site’s population health initiatives and projects
Interacts with appropriate internal and external parties to gain an understanding of factors that affect the quality performance data for their site
Serves as source of information and clarification for most questions related to quality metrics and provides guidance in understanding the data to members of the care team (physician, MA, leadership, etc.). Usually refers complex questions to site leadership or central quality department
Helps to ensure the integrity and accuracy of the data, notifies Quality Department or site leadership of any inconsistencies in the data so that the aforementioned person(s) can resolve the issue with the appropriate resource
Independently evaluates metrics and potential courses of action and presents recommendation to site leadership. Advocates to local management for development of initiatives to improve point of care processes related to population management/quality.
Trains new clinicians and staff on the specifics of the quality metrics and workflows directly related to improving care/metric performance
Attends required monthly population management meeting to learn from other population management coordinators around the organization
Performs other duties as assigned