Population Health Coordinator (Greater Roslindale Medical Ctr)

POSITION SUMMARY:

Under the supervision of the Value based Care Manager, the Population Health Coordinator / Quality Specialist is responsible for a wide range of Quality activities, including providing outreach and supporting patients to receive optimal population health management for preventive care and chronic disease management. Responsible for documentation in the electronic medical record and complying with all data entry, data integrity, and data tracking requirements for GRMDC, BMC and funding agencies' contract monitoring reports as required. The Quality Specialist will also assist the Leadership Team in developing and implementing new programs and systems for Population Health Management. Activities include the collection, analysis and reporting of quality data. Position is also responsible for providing guidance on a site-specific metrics program, designed to ensure continuous improvement throughout the organization.

Position: Population Health Coordinator

Department: Roslindale Medical and Dental Center

Schedule: Full Time

ESSENTIAL RESPONSIBILITIES / DUTIES:

Outreach efforts

• Monitors patients' progress via registry and EMR, following up with patient and primary care provider as necessary.

• Conducts and coordinates timely, proactive patient outreach (telephonic, written, and in clinic) to schedule follow up appointments, coach patients as they prepare for appointments and/or routine screenings, and provide pre-visit reminders as needed. Follows up on patients who cancel or do not arrive to their appointments.

• Provides education, counsels, and supports to our patients. Uses a variety of culturally, linguistically and educationally appropriate strategies, in a variety of settings. Coordinates with Interpreter Services, as needed.

• Identifies patients whose chronic conditions require increased surveillance to maintain good health and minimize complications.

• Collaborates and coordinates with health care team members, including social work and other resources to promote positive prevention & harm reduction.

Program Development:

• Collaborates with Leadership and project management team to develop pilot projects and scale up Quality Program at GRMDC.

• Refines outreach, pre-visit and post-visit workflows as needed

• Collaborates with other departments to improve efficiency and care coordination

Tracking and Reporting:

• Utilize registry/EMR to generate reports that will inform the population health management program

• Develop and utilize dashboard for tracking effectiveness of programs and/or pilots

• Requires analytic capabilities and Microsoft Excel skills

• Will manage large data sets and run analyses to monitor program effectiveness and adjust processes as necessary

• Performs detailed analyses and provides recommendations for continuous improvement activities, based on the data collected.

• Abstracts clinical data for HEDIS and other quality incentives

• Conducts chart reviews to ensure proper documentation for quality reporting.

• Ability to summarize data & outreach efforts for reporting purposes

Knowledge Base:

• Demonstrates working knowledge of accountable care organization structure and requirements.

• Demonstrates knowledge of quality measures/specifications.

• Demonstrates an understanding of quality concepts.

Meets hospital-wide standards in the following areas:

• Conforms to GRMDC/BMC standards of performance and conduct, including those pertaining to patient rights and privacy

• Utilizes GRMDC/BMC policies and standards as the basis for decision making and to support the mission and goals.

• Follows established GRMDC/BMC infection control and safety procedures

OTHER DUTIES:

• Coordinates and provides trainings for patient navigators and care coordinators at community health centers

• Provides other administrative and special project assistance as required or assigned by Operations Manager

• Remains knowledgeable of and follows appropriate policies, procedures, and work standards, including but not limited to, policy regarding hours of work, absenteeism, and tardiness.

• Maintains competency in areas of responsibility to ensure quality of care.

• Maintains strict protocols of all confidential or sensitive information

• Attends hospital required and relevant training sessions or activities, as assigned by Operations Manager.

• Promotes a positive and collaborative work environment supportive of GRMDC/BMC mission and goals.

• Provides a link between the GRMDC and other departments.

• Adapts to changing departmental needs, including but not limited to, offering assistance to other team members, adjusting assignments, and other functions as determined by Operations Manager.

• Assists in orientation/training of new staff members and volunteers.

• Performs other duties assigned or as necessary.

Must adhere to all of BMC's RESPECT behavioral standards.

(The above statements in this job description are intended to depict the general nature and level of work assigned to the employee(s) in this job. The above is not intended to represent an exhaustive list of accountable duties and responsibilities required).

JOB REQUIREMENTS

EDUCATION:

• College degree preferred or equivalent education and experience. Experience in the healthcare field and utilization of OCHIN or EPIC is an advantage

EXPERIENCE:

• 3-5 years of relevant experience preferred

• Experience managing/supervising personnel/team strongly preferred.

KNOWLEDGE AND SKILLS:

• Knowledge of community, social, and health resources.

• Expertise in establishing working relationships with patients, their family, professionals, and the community, including the ability to collaborate with a multidisciplinary health care team.

• Computer competency, inclusive of the ability to access, enter and analyze data.

• Ability to work in a fast paced environment, inclusive of organizational skills, critical thinking, and problem solving abilities.

• Effective verbal, written, and interpersonal communication skills to facilitate interactions with various members of the health care team, patients, and their families. Impeccable phone etiquette.

• Bilingual or multi-lingual skills (beyond that of English) appropriate to the patient population served, is preferred.

• Sensitivity to ethnic, cultural, gender, and sexual orientation diversity; values; beliefs; and behaviors.

• Demonstrated critical thinking and problem solving ability.

• Medical Terminology

• Experience with EPIC/OCHIN, Microsoft Office - Excel, Word, PowerPoint and Outlook

• Experience with Microsoft Excel formulas, including VLOOKUP functions and Pivot tables

Equal Opportunity Employer/Disabled/Veterans