Population Health Coordinator

About Us

As a not-for-profit organization, Mass General Brigham is committed to supporting patient care, research, teaching, and service to the community by leading innovation across our system. Founded by Brigham and Women's Hospital and Massachusetts General Hospital, Mass General Brigham supports a complete continuum of care including community and specialty hospitals, a managed care organization, a physician network, community health centers, home care, and other health-related entities. Several of our hospitals are teaching affiliates of Harvard Medical School, and our system is a national leader in biomedical research.

We're focused on a people-first culture for our system's patients and our professional family. That's why we provide our employees with more ways to achieve their potential. Mass General Brigham is committed to aligning our employees' personal aspirations with projects that match their capabilities and creating a culture that empowers our managers to become trusted mentors. We support each member of our team to own their personal development-and we recognize success at every step.

Our employees use the Mass General Brigham values to govern decisions, actions, and behaviors. These values guide how we get our work done: Patients, Affordability, Accountability & Service Commitment, Decisiveness, Innovation & Thoughtful Risk; and how we treat each other: Diversity & Inclusion, Integrity & Respect, Learning, Continuous Improvement & Personal Growth, Teamwork & Collaboration.

General Overview

The Population Health Management (PHM) team works with the health system and community partners to develop, implement, and manage value-based care strategies that improve patient outcomes and reduce the cost of care. Our goal is to make care more affordable while addressing the health needs of our patients and communities.

Our multi-disciplinary team is comprised of forward-thinking individuals who can reimagine care models that meet the needs of the communities we serve. When you join the PHM team, you become a part of a team that strives to reinvent how care is delivered.

The Population Health Coordinator (PHC) is an integral member of a data-driven Ambulatory Quality team that proactively seeks to optimize preventive and chronic disease care. Centrally based PHCs are assigned to support ambulatory practices and are expected to function as innovative and critical members of both their central team and practice-based teams.

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. PHCs facilitate high-value, patient-centered care that improves timely access to and provision of preventive services and chronic disease treatment.

Key Areas of Responsibility:

• Gathers and manages quantitative and qualitative patient data using population registries and evidenced-based assessment tools

• Learns and understands Primary Care practice workflows with respect to optimal and coordinated health care for target patient populations

• Develops a keen understanding of primary care practice requirements

• Manages patient data collection and generates reports for analysis

• Conducts timely outreach tailored to meet each patient's condition-specific needs

• Contributes to Quality Improvement and Process Design of Population Health efforts

• Follows established communication protocols and informs clinical team and program leadership accordingly

• Participates in improvement projects within Population Health programs

Principle Duties and Responsibilities:

• Manage patient registries and provide the members of health care teams with the data required to meet the health needs of the practice

• Support PHM staff to develop creative processes to proactively manage target populations and provide data support and population health education when applicable

• Provide data management, coordination, and patient outreach as needed for

specific target patient populations

• Respond to inquiries from designated practices in a timely manner

• Assist in process mapping and development of workflows for population health management at each of the designated primary practices

• Answer and/or research questions on problems the clinicians have identified

• Recognize and report data inconsistencies to appropriate personnel

• Help mentor new hires during the onboarding process and assist in cross coverage as needed

• Contribute to the teamwork within and between departments. Regularly attend and participate in meetings with coworkers and practice staff. Provide constructive ideas, suggestions, and feedback in a positive manner. Work collaboratively with co-workers to effectively resolve issues that impact departmental or hospital operations

• Perform all job functions in compliance with applicable federal, state, local and company policies and procedures

• Attend practice and central team meetings as directed

• Other duties as assigned

Quality Improvement and Process Design

• Collaborates with care teams to establish culturally sensitive, population-based interventions and workflows to reconnect patients to care

• Works closely with practice teams planning tests of change by participating in the planning, implementation and analysis of PDSA improvement cycles as appropriate

• Monitors and corrects population registries under the direction of the Provider and the care teams within the practice

Other duties as assigned

Qualifications

• Bachelor's degree preferred

• Minimum of 2 years' experience in customer service or in a health care setting. Experience in promoting healthcare behavior change is desirable

• Proficient in data management and reporting

• Proven problem-solver with ability to multi-task

• Prior use of electronic health records and other health care information systems desirable

Skills, Abilities and Competencies

• Strategic problem solving: Able to take initiative to solve problems and resolve issues; is resourceful in finding required data and recommending solutions.

• Interpersonal/communication: strong interpersonal skills, including customer service orientation. The ability to interact with faculty, Medical Directors, senior Department leadership, trainees, and others in a knowledgeable, confident and professional manner.

• Attention to detail: Commitment to accuracy and integrity of all data, reports, and communications.

• Discretion and confidentiality: Ability to handle sensitive and confidential matters discreetly; ability to skillfully handle issues of sensitive nature with respect to confidentiality.

• Organization. Exceptional organizational skills and ability to prioritize effectively, asking for direction when appropriate.

• Capable of working cross-functionally. Ability to thrive and lead in a highly matrixed, collaborative, team-oriented environment. Ability to build consensus through negotiation and diplomacy and get work done through others

• Communication. Comfortable interacting with senior leaders and facilitating teams of clinical leaders and senior managers

• Flexibility. Flexible and adaptable within a complex, multi-site environment with changing requirements

Working Conditions

• Split of office and remote working setting

• Job responsibilities include heavy computer work and occasional work outside of regular business hours.