Talent.com
Population Health Coordinator
Population Health CoordinatorFenway Health • Boston, MA, United States
Population Health Coordinator

Population Health Coordinator

Fenway Health • Boston, MA, United States
4 days ago
Job type
  • Full-time
Job description

Apply

Job Type

Full-time

Description

Under the supervision of the Manager of Population Health & ACO Performance, the Population Health Coordinator (PHC) supports the organization's efforts to improve the health of the patient population through patient outreach and engagement in care and data capture improvement efforts.

Responsibilities

The Population Health Coordinator plays a key role in the Health Center's Quality Improvement efforts by routinely collaborating with Quality team members, Medical Assistants (MAs), Nurses, Providers, and Operations staff to track care, close patient care gaps, and maintain accurate data in the EHR. Key duties include :

Data Capture and Improvement Efforts :

  • Leverages available information and reports from the current Epic electronic health record (EHR), the legacy EHR (Athena Practice) and population health platforms, including Arcadia, to locate missing patient care gap data and outside results. Examples include and are not limited to colonoscopies, diabetic retinal exams, mammograms, and external lab results (HbA1c, Cologuard, PAP smears / HPV testing)
  • Accurately records care gap data and external results into the Epic EHR to ensure structured data is captured for quality measure reporting.
  • Appropriately updates Health Maintenance Care gaps based on care gap data located
  • Documents patient exclusions from care gaps, as appropriate, within the EHR and through any payer-specific exclusion workflows.

Patient Outreach and Engagement in Closing Care gaps

  • Initiates outreach to patients via reminder letter, telephone call, secure text message, or MyChart message to schedule appointments and remind patients about overdue care, including procedures, lab tests, and appointments related to quality metrics or annual wellness visits.
  • Works with patients to obtain outside records of care that address care gaps and enters data as appropriate into the EHR.
  • Addresses patient replies to outreach campaigns appropriately and in a timely manner.
  • Utilizes motivational interviewing skills, as necessary, to appropriately engage patients, directing and receiving support from the clinical care team(s) when necessary
  • Documents outreach and other notes in the EHR and other databases to document outreach and to communicate to clinical and teams' information about care that is due for individual patients
  • Engage patients in conversation to uncover challenges they face in accessing services (i.e. transportation, housing instability, financial hardship, language barriers) and collaborate with care teams to connect patients with resources.
  • Supports ongoing reporting for program oversight and management :

  • Tracks outreach efforts and audit activities and provides summary progress reports to leadership
  • Coordinates with specialties and primary care to remind team members of open care gaps.
  • Generates and distributes patient registry reports, as needed.
  • Conducts chart audits for data validation and to identify opportunities for improvement.
  • Conducts chart audits for referrals, test tracking and lab / imaging tracking and implements protocols to administratively close the loop for tracking, as appropriate
  • Adheres to all agency and departmental policies and procedures
  • Upholds the principles of customer service in all interactions with all co-workers, patients, and external stakeholders
  • Participates in additional quality improvement activities, elevating patient stories and trends that highlight gaps in care delivery or access
  • Adheres to the highest principles of patient and client confidentiality
  • Adheres to established safety policies, procedures and precautions; identifies potential or actual unsafe situations in the environment and informs appropriate staff
  • Attends all required meetings, in-services and professional training
  • Performs related duties as required
  • Requirements

  • Strong Electronic Medical Record skills, including medical terminology and understanding of clinical quality data
  • Highly organized and self-motivated individuals with the ability to work autonomously
  • Well-developed analytic and writing skills required
  • Ability to work harmoniously and effectively with colleagues, patients, clients and vendors across the spectrum of diversity, including but not limited to race, ethnicity, color, gender identity, sexual orientation, age, socio-economic status, national origin and immigrant status, religious or spiritual identity, disability (physical, mental, emotional and developmental), veteran status, and / or limited English proficiency.
  • Willingness to contribute towards Fenway's efforts in becoming an anti-racist organization and promoting a culture dedicated to ongoing development in service of humility, equity, diversity, inclusion, and belonging, where differences are acknowledged and valued.
  • Proficient in MS Word, Excel, and PowerPoint.
  • High school diploma or GED
  • At least 2 years of relevant experience in healthcare
  • Preferred Qualifications :

  • Epic medical record experience
  • Clinical training / background
  • Training in motivational interviewing
  • Working knowledge or familiarity with electronic health records and other health care IT systems
  • Working knowledge of clinical quality metrics such as HEDIS NCQA or UDS metrics
  • Patient-focused experience or customer service background
  • Fluent in Spanish
  • Bachelors degree
  • This is a union position in a Fenway Health bargaining unit represented by 1199 SEIU United Healthcare Workers East.

    We offer competitive salaries, and for those who qualify, an excellent benefits package; including comprehensive medical and dental insurance plans, and a retirement plan with employer match. We also provide 11 paid holidays, paid vacation, and more. LGBTQIA+ identified persons, Black, Indigenous, and other people of color (BIPOC), and individuals from other historically underrepresented communities are strongly encouraged to apply.

    Salary Description

    25.74-32.15

    Create a job alert for this search

    Population Health Coordinator • Boston, MA, United States

    Related jobs
    Telecommute Healthcare Advocate (Field Based)

    Telecommute Healthcare Advocate (Field Based)

    UnitedHealth Group • Boston, MA, United States
    Full-time
    Functioning independently, travel across assigned territory to meet with providers to discuss Optum tools and programs focused on improving the quality of care for Medicare Advantage Members.Will b...Show more
    Last updated: 30+ days ago • Promoted
    Healthcare Consultant

    Healthcare Consultant

    VirtualVocations • Lowell, Massachusetts, United States
    Full-time
    A company is looking for an Associate Partner, Academic Alignment, Strategic Transformation.Key Responsibilities Lead the problem-solving process and manage engagement teams, overseeing analysis ...Show more
    Last updated: 14 days ago • Promoted
    Washington Licensed Behavioral Health Navigator

    Washington Licensed Behavioral Health Navigator

    VirtualVocations • Dorchester, Massachusetts, United States
    Full-time
    A company is looking for a Behavioral Health Navigator SW.Key Responsibilities Conduct mental health assessments and safety planning for emergency department patients Create outpatient plans and...Show more
    Last updated: 5 days ago • Promoted
    Health Navigator, Sexual Health

    Health Navigator, Sexual Health

    Fenway Health • Boston, MA, United States
    Full-time
    Reporting to the Sexual Health Program Manager, the Health Navigator provides outreach, risk-reduction counseling and HIV / Hepatitis C / STI screening services, check-in, and linkage to care services ...Show more
    Last updated: 30+ days ago • Promoted
    New Jersey Licensed Clinical Navigator

    New Jersey Licensed Clinical Navigator

    VirtualVocations • Dorchester, Massachusetts, United States
    Full-time
    A company is looking for a Clinical Navigator - Cardiovascular - RN.Key Responsibilities Serves as a single point of contact for referring physicians, patients, and caregivers to provide resource...Show more
    Last updated: 1 day ago • Promoted
    Brand Health Accountability Specialist

    Brand Health Accountability Specialist

    VirtualVocations • Dorchester, Massachusetts, United States
    Temporary
    A company is looking for a Brand Health Accountability Specialist for a 6-month contract.Key Responsibilities Oversee team communication channels and manage project activities for Brand Health Ac...Show more
    Last updated: 25 days ago • Promoted
    Healthcare Coordinator

    Healthcare Coordinator

    Element Care • Lowell, MA, US
    Full-time
    Great Life work Balance position with excellent benefits! .Participates as a member of the PACE Interdisciplinary Team in the planning, implementation and evaluation of care plans that meet the obj...Show more
    Last updated: 22 hours ago • Promoted • New!
    Cancer Registrar

    Cancer Registrar

    Emerson Hospital • Concord, MA, United States
    Full-time
    Clerical & Administrative Support.Old Road to Nine Acre Corner, Concord, MA 01742 .Reporting directly to the Cancer Services Manager, interacting with physicians, patients and other hospital st...Show more
    Last updated: 30+ days ago • Promoted
    Senior Population Health Specialist

    Senior Population Health Specialist

    VirtualVocations • Lowell, Massachusetts, United States
    Full-time
    A company is looking for a Senior Population Health Strategy Specialist.Key Responsibilities Develops and designs complex population health strategy initiatives and operational plans to improve c...Show more
    Last updated: 3 days ago • Promoted
    Bilingual Clinical Associate

    Bilingual Clinical Associate

    VirtualVocations • Lowell, Massachusetts, United States
    Full-time
    A company is looking for a Clinical Associate - Bilingual Spanish.Key Responsibilities Coordinate care and manage orders for palliative and hospice services, ensuring timely support for members ...Show more
    Last updated: 30+ days ago • Promoted
    Licensed Behavioral Health Case Manager

    Licensed Behavioral Health Case Manager

    VirtualVocations • Lowell, Massachusetts, United States
    Full-time
    A company is looking for a Clinical Case Manager Behavioral Health - Work at Home.Key Responsibilities Conduct holistic assessments to identify member needs and eligibility Develop and monitor i...Show more
    Last updated: 30+ days ago • Promoted
    New York Licensed Clinical Reviewer

    New York Licensed Clinical Reviewer

    VirtualVocations • Lowell, Massachusetts, United States
    Full-time
    A company is looking for a Clinical Review Clinician - Appeals.Key Responsibilities Performs clinical reviews to resolve and process appeals by analyzing medical records and clinical data Ensure...Show more
    Last updated: 30+ days ago • Promoted
    Patient Advocate

    Patient Advocate

    VirtualVocations • Lowell, Massachusetts, United States
    Full-time
    A company is looking for a Member Services Patient Advocate.Key Responsibilities Manage member phone line and address all inquiries related to balance billing Ensure timely responses to member i...Show more
    Last updated: 30+ days ago • Promoted
    Pre-Registration Specialist

    Pre-Registration Specialist

    VirtualVocations • Lowell, Massachusetts, United States
    Full-time
    A company is looking for a Pre Registration Specialist to confirm patient information and discuss liabilities prior to service. Key Responsibilities Confirm and collect patient information and lia...Show more
    Last updated: 30+ days ago • Promoted
    Senior Clinical Coordinator

    Senior Clinical Coordinator

    VirtualVocations • Lowell, Massachusetts, United States
    Full-time
    A company is looking for a Senior Clinical Coordinator - Clinical Operations.Key Responsibilities Manage and track client cases, conduct data analysis, and follow up on case activities Support s...Show more
    Last updated: 30+ days ago • Promoted
    Health Consultant

    Health Consultant

    VirtualVocations • Lowell, Massachusetts, United States
    Full-time
    A company is looking for a Health Consultant / Customer Experience Representative.Key Responsibilities Handle daily client interactions via multiple communication channels with professionalism Man...Show more
    Last updated: 12 days ago • Promoted
    Behavioral Health Substance Use Disorder Specialist

    Behavioral Health Substance Use Disorder Specialist

    Fenway Health • Boston, MA, United States
    Full-time
    Under the general supervision of the Manager of Integrated Behavioral Health Services, the Behavioral Health Specialist with specialty in evaluating and treating substance use disorder (SUD) provid...Show more
    Last updated: 30+ days ago • Promoted
    Clinical Sourcer

    Clinical Sourcer

    VirtualVocations • Lowell, Massachusetts, United States
    Full-time
    A company is looking for a Clinical Sourcer.Key Responsibilities Proactively identify and engage clinical professionals through various sourcing channels Build and maintain a pipeline of high-qu...Show more
    Last updated: 3 days ago • Promoted