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
2 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
    Community Health Worker

    Community Health Worker

    Fenway Health • Boston, MA, United States
    Full-time
    Community Health Worker (CHW) will with specific target populations on identifying and address Social Determinants of Health (SDoH). CHWs will work closely with medical providers, primary care teams...Show more
    Last updated: 30+ days ago • Promoted
    Medical Care Coordinator

    Medical Care 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: 23 hours ago • Promoted
    Behavioral Health Assistant

    Behavioral Health Assistant

    Health Advocates Network • Danvers, MA, US
    Full-time
    Comprehensive health, prescription, dental, vision, life, and disability plans.Referral opportunities? Refer a friend & Cash in!. Travel reimbursement and per diem allowances.Health Advocates Networ...Show more
    Last updated: 15 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: 23 hours ago • Promoted
    Member Care Navigator / Community Health Coordinator

    Member Care Navigator / Community Health Coordinator

    Better Life Partners • Boston, MA, US
    Full-time
    At Better Life Partners, we provide what it takes to heal from addiction.We work alongside community-based organizations to meet our members where they are, no matter what recovery looks like to th...Show more
    Last updated: 16 days ago • Promoted
    Clinical Services Coordinator

    Clinical Services Coordinator

    VirtualVocations • Lowell, Massachusetts, United States
    Full-time
    A company is looking for a Clinical Services Coordinator to ensure a seamless and positive patient experience.Key Responsibilities Serve as the primary point of contact for all patient communicat...Show more
    Last updated: 1 day ago • Promoted
    Healthcare Administrative Coordinator

    Healthcare Administrative Coordinator

    VirtualVocations • Lowell, Massachusetts, United States
    Full-time
    A company is looking for a Healthcare Administrative Coordinator.Key Responsibilities Monitor and triage incoming emails and calls Assign and enter staff schedules into the scheduling platform ...Show more
    Last updated: 1 day ago • Promoted
    Master's Level Clinician (Seeking LICSW) - Fee For Service

    Master's Level Clinician (Seeking LICSW) - Fee For Service

    Thriveworks • Cohasset, MA, US
    Full-time
    Thriveworks is currently seeking individuals pursuing Massachusetts Licensure as an LICSW in Quincy, MA to provide a mix of telehealth and face-to-face sessions. This role is eligible for a $7,500 r...Show more
    Last updated: 1 day ago • Promoted
    Senior Population Health Specialist

    Senior Population Health Specialist

    VirtualVocations • Dorchester, 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: 2 days ago • Promoted
    Community Engagement Coordinator

    Community Engagement Coordinator

    VirtualVocations • Lowell, Massachusetts, United States
    Full-time
    A company is looking for a Community Engagement Coordinator.Key Responsibilities Manage and coordinate research activities for a grant-funded project in designated Virginia counties Engage with ...Show more
    Last updated: 30+ days ago • Promoted
    Community Engagement Coordinator (PDF)

    Community Engagement Coordinator (PDF)

    Town of Lexington • Lexington, MA, United States
    Part-time
    We are currently accepting applications for the part-time (15 hours per week) position.Community Engagement Coordinator.The REQUIRED Town of Lexington application form. Town's Human Resource Departm...Show more
    Last updated: 18 days ago • Promoted
    Intake Coordinator

    Intake Coordinator

    Brockton Area Multi-Servi • Brockton, MA, US
    Full-time
    Intake Coordinator (CSA / FIT Program).We are a trusted partner in providing critical behavioral health services to children, youth, and families, helping them build supportive connections within t...Show more
    Last updated: 30+ days ago • Promoted
    Community Engagement Coordinator (PDF)

    Community Engagement Coordinator (PDF)

    Town of Lexington Massachusetts • Lexington, MA, United States
    Part-time
    We are currently accepting applications for the part-time (15 hours per week) position.Community Engagement Coordinator.The REQUIRED Town of Lexington application form. Town's Human Resource Departm...Show more
    Last updated: 1 day ago • Promoted
    Behavioral Health Social Worker

    Behavioral Health Social Worker

    Element Care • Lowell, MA, US
    Full-time
    Great Life work Balance position with excellent benefits! .The Element Care Social Worker participates in the planning, implementation and evaluation of care plans that meet the objectives, standar...Show more
    Last updated: 23 hours ago • Promoted
    Health Services Review Coordinator

    Health Services Review Coordinator

    VirtualVocations • Lowell, Massachusetts, United States
    Full-time
    A company is looking for a HS Review Coordinator II responsible for coordinating and supporting intake functions within the Utilization Management Department. Key Responsibilities Triage, research...Show more
    Last updated: 3 days ago • Promoted
    Research and Evaluation Coordinator

    Research and Evaluation Coordinator

    VirtualVocations • Lowell, Massachusetts, United States
    Full-time
    A company is looking for a Coordinator of Research and Evaluation.Key Responsibilities Organizes literature on scratch cooking in schools and summarizes key takeaways for program evaluation Mana...Show more
    Last updated: 2 days ago • Promoted
    Behavioral Health Intake and Utilization Review Coordinator

    Behavioral Health Intake and Utilization Review Coordinator

    CharterCARE Health Partners • Providence, Rhode Island, United States, 02908
    Full-time
    Behavioral Health Intake and Utilization Review Coordinator.The Behavioral Health Intake and Utilization Review Coordinator is responsible for bed management, reviewing intake assessments, verifyin...Show more
    Last updated: 12 days ago
    Licensed Wellness Coordinator

    Licensed Wellness Coordinator

    VirtualVocations • Lowell, Massachusetts, United States
    Full-time
    A company is looking for a Coordinator Member Wellness.Key Responsibilities Maintain ongoing communication and health coaching with members regarding wellness initiatives Utilize motivational in...Show more
    Last updated: 4 days ago • Promoted