POSITION TITLE: Population Health Coordinator
REPORTS TO: Director of Quality & Process Improvement
FLSA Status: Non-Exempt
Date: January 2024
General Definition and Scope of Job
This position is responsible for the coordination and implementation of quality projects to improve the organization’s approach and compliance with cancer screenings and other population health measures through direct patient outreach, chart management and review, interdepartmental collaboration, and tracking of patients, results, and referrals. This position also works to positively influence patients’ understanding of preventative care and improved health outcomes. Knowledgeable about community health centers, federally qualified health centers, and local resources for obtaining preventative healthcare services. Supports the tenets of value-based care and the quintuple aim of health care.
Core Responsibilities
•Conducts and documents member outreach via phone, letter, portal, and other available patient engagement resources to educate patients and connect them to available organization and community resources for preventative health
• Assist with development and implementation of clinical outreach materials such as scripts, e-mails, flyers, outreach campaigns
• Develops communication pathways with external partner agencies
• Tracks patients to ensure completion of tests, labs, referrals, and appointments for chronic disease management and preventative care; follows up on open items and collaborates with clinical team
• Creates patient care registries for chronic disease and preventative care using data from EMR and other population health tools, shares registries as needed with clinical teams to support tracking and monitoring
• Assists with data collection, data entry into EMR or excel spreadsheets as required, and tracking of population health measures and outreach efforts
• Performs chart review and data validation tasks, ensuring that data is correctly entered and labeled with EMR, managing any documentation discrepancies
• Participates in projects to address gaps in care and actively seeks to identify and eliminate disparities through Plan-Do-Study-Act (PDSA) cycles to improve processes and workflows
• Tracks and reports out on project performance to multi-disciplinary stakeholders
• Participate in care team meetings, quality meetings, and site meetings as required to update on performance, outcomes, workflow changes
Critical Demands of the Job
• Manage multiple requests and prioritize appropriately.
• Ability to function in a faced paced setting.
• Attention to details and prompt follow up.
• Excellent organizational and interpersonal skills.
• Willingness to pivot and adapt to changes in process and technologies.
Minimum Skills, Experience and Educational Requirements Education:
• Competent with Microsoft, particularly Word/Excel
• Prior use and experience with Electronic Medical Records desirable
• Verbal and written communication skills
• Highly organized with excellent attention to detail
• Excellent customer service skills
Required Certifications and Licenses
• LPN or Medical Assistant Certificate
Working Conditions
• Works in well-lighted environment with comfortable surroundings.
• Stressful at times due to competing demands.