The Population Health Coordinator supports the development of patient-centered, team-based care. S/he will support primary care physicians (PCPs) and their associated care teams in managing their panel of patients using a registry population management informatics tool. By gathering and organizing patient data, the Population Health Coordinator works to identify patients’ unmet needs, engage patients in their own care, gather summary information for treatment interventions, and enhance ongoing communication between the patient and her/his care team. The goal of the PHM program is to facilitate high-value, patient-centered care that improves timely access to and provision of preventive services and treatment of chronic conditions.
Key Areas of Responsibility:
Develops an understanding of health center primary care practice requirements for optimal, coordinated population health.
Works as an effective team member of the Population Health Management program
Manages data collection using a registry, prepares reports on findings, and provides interpretations and recommendations to each center.
Contributes to quality improvement and care redesign of population health efforts
Principle Duties and Responsibilities:
Manage patient registries and provide the members of health care teams in health center practices with the data required to meet the health needs of the practice.
Recognize and report data inconsistencies to appropriate personnel
Provide data management, coordination, and patient outreach as needed for specific target patient populations.
Makes outreach phone calls to interact with patients and call them in for necessary healthcare appointments.
Support practice staff to develop creative processes to proactively manage target populations.
Performs clinical quality audits that contribute to elevate the standard of operation and care we provide to patients.
Contributes to a positive experience for patients and families through courteous telephone interactions, and referrals to appropriate clinical staff when necessary.
Assist in process mapping and development of workflows for population health management at each of the clinics.
Regularly attends and participates in meetings with coworkers and clinic staff
Provides constructive ideas, suggestions and feedback in a positive manner
Works collaboratively to effectively resolve issues that impact program operations
Perform all job functions in compliance with applicable federal, state, local, company, and funder policies and procedures.
Bi-Lingual (Spanish language fluency) required
High school diploma required. Bachelor’s degree preferred
Minimum of 2 years’ experience in customer service, community health, or in a health care setting.
Experience in promoting healthcare behavior change is desirable.
Working knowledge of computer software, including Excel, PowerPoint and Word.
Proficient in data management and reporting
Ability to work with large data sets with guidance from medically trained individuals
Prior use of electronic health records and other health care information systems desirable (NextGen, and/or
i2iTracks experience a plus). Experience with NextGen and all its modules a plus and highly desired.
Ability to identify problems, think creatively, and devise innovative solutions
Proven problem-solver with ability to multi-task, highly organized, proactive and attentive to details
Strong interpersonal skills· Ability to work as member of a collaborative team
Ability to persuade, influence and enlist others’ support in accomplishing objectives
Excellent writing and oral presentation skills