General Description of the Job Class
Responsible for the coordination and assistance of the administrative functions for population health which include, Patient Center Medical Home (PCMH) and Comprehensive Primary Care Plus (CPC+). This position helps to ensure that patients receive appropriate overall medical care in an effort to maximize wellness or to manage complex, chronic health conditions. The Population Health Specialist is responsible and accountable for supporting clinical expertise for specific complex patient populations. The Population Health Specialist functions as an integral part of an interdisciplinary team, ensuring excellence in patient care, in an effort to achieve optimal clinical outcomes through a seamless model of access and care. Focus on improving transitions in care for patients, physicians, family and community.
Patient base consists of patients who are sub-optimal users of healthcare and/ or management of chronic disease. Identify barriers to proper utilization and determine best steps for following treatment recommendations, as well as providing resource/ benefit education.
Duties and Responsibilities of this Level
· Effective communication with all staff members
· Build effective and trusting relationships with patient/peers
· Data mining to obtain results of lab, preventative screenings and clear documentation of such data
· Researching to find gaps in care for above mentioned programs
· Patient outreach including communication to promote preventative health to ensure the quality care of our patients
· Data mining to obtain correct diagnosis and compliance of beneficiaries that participate in above programs
· Use data to analyze trends and to verify data
· Follow-up with patients and providers on identified health care needs and identify possible resources to address those concerns and/ or work with care management team to address concerns in a multidisciplinary method.
· Provide individual contact to patients on health education issues. Develop the health awareness of individuals empowering them to make better health choices.
· Monitor access to care, services, and treatment including linkage to the medical home.
· Document and communicate with all provider(s) and member(s) of the care team as needed to minimize fragmented care.
· Contact patients for pre-visit planning for various aspects of the programs
· Contact patients for follow-up care plans for high risk patients
· Performs day-to-day administrative functions and general office duties including but not limited to word processing, copying, filing, faxing, answering phones and data entry.
High School Diploma
CCMA, RMA, CMA or LPN
Customer service experience and/or clinical experience preferred.
Degrees, Licensure, and/or Certification:
CCMA, RMA or CMA within 6 months of employment unless LPN.
Knowledge, Skills, and Abilities:
Must be able to read, write, speak and understand English.
The work activity and patient acuity levels can create a stressful atmosphere, therefore individuals successful in this job are:
- Organized and motivated by a fast-paced environment
- Able to manage multiple tasks/projects simultaneously
- Proficient in review and assess needs quickly
- Strong with the use of computer software tools and data files
- Comfortable with continuous change and self-initiating
Able to complete documentation in a quick and efficient manner
Ability to effectively engage in patient outreach. Ability to assimilate accurate information and make quality decisions based on data gathered
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