The Population Health Specialist will serve to improve quality of care by linking CMC patients to needed care. This will include using reports, health information technology (HIT) and registries to identify patient and population gaps in care, collaborate with health care team/provider to confirm needs, communicate with patients about needed care, and follow up to ensure patients receive care. The Population Health Coordinator is responsible for conducting these activities directly, and in collaboration with others. The Population Health Specialist is responsible for facilitating the in-reach, communication, and accommodation of patients who are due for preventive services and/or have identified gaps in care at each site. The Population Health Specialist will report to the Center Manager and will work closely with the Population Health Coordinator, QI team and the Chief Medical Officer. The Population Health Specialist reports to their home site Center Manager.
High School Diploma or GED
At least 2 years of experience as a Medical Assistant, Medical Receptionist, and/or healthcare position is required.
Proficient experience with handling NextGen electronic health record data
Ability to communicate effectively both verbally and in written format
Proficient in Microsoft Office (including Word, Excel and Powerpoint)
Valid California Driver's License, proof of insurance and personal transportation
General knowledge of Healthcare Effectiveness Data and Information Set (HEDIS) measures is preferred
Direct communication with all members of the care team
Monitors care team panel adherence
Performs care team patient in-reach and schedules appointments for patients with gaps in care
Regular meetings with the Population Health Coordinator
Reports member access challenges to Population Health Coordinator
Monitors gap in care lists for patients assigned to care team panel
In-reach non-engaged patients (patients who have not been seen in the past year)
Sends in-reach letters to patients with identified gaps in care
Ensure team huddles happen, pre visit planning is done, and manage inbox and other admin tasks as assigned
Ensure timely chart completion and monitor kept appointments with no charges reports on a daily basis
General knowledge of CMC and Clinical Performance Goals
Able to ask questions if there is a lack of understanding on procedure
Participates in meetings as required
Travels as needed to different sites as assigned
Performs other tasks as assigned
Knowledge, Skills and Abilities
Knowledge of business office procedures
Knowledge of Excel (Intermediate; proficient experience preferred)
Knowledge of grammar, spelling, and punctuation to type patient information
Skill in operating computer, photocopy and facsimile (FAX) machine
Skill in greeting patients and answering the telephone in a pleasant and helpful manner
Ability to establish and maintain effective working relationships with patients, employees, and the public
Ability to multi-task
Listens skillfully and displays a willingness and ability to acknowledge the needs, expectations and values of others through the use of reflective listening and empathy conveyance; responds to needs in ways that are helpful and beyond expectation.
Communicate effectively by using welcoming words, proper tone of voice, appropriate body language, eye contact and smiling with every interaction
Ability to provide excellent customer service that is reflective of a culture that values trust and respect.
TYPICAL PHYSICAL DEMANDS:
Work may require sitting for long periods of time; also stooping, bending and stretching for files and supplies. Occasionally lifting files or paper weighing up to 35 pounds. Requires manual dexterity sufficient to operate a keyboard, type at 35 wpm, operate a computer, calculator, telephone, copier, and such other office equipment as necessary. Vision must be correctable to 20/40 and hearing must be in the normal range for telephone contacts. It is necessary to view and type on computer screens for long periods and to work in an environment which can be very stressful.
TYPICAL WORKING CONDITIONS:
Work performed in reception, medical records, and cashier areas. Involves frequent contact with patients. Work may be stressful at times. Interaction with others is constant and interruptive. Contact involves dealing with sick people. Frequent exposure to communicable diseases, toxic substances and other conditions common to a clinic environment.