Population Health Specialist

OUR VISION

To continue as an eminent healthcare provider on Long Island, dedicating ourselves to providing exceptional health care for all our patients and to transform both the lives of the individual, and the community, for the better, one person at a time.

OUR MISSION

To provide access to equitable, optimal healthcare by improving the overall wellness of all individuals in our communities and delivering high quality comprehensive patient centered care.

OUR VALUE PROPOSITION

To provide whole person care that will ensure that all patients have access to primary, specialty and social health care to achieve and maintain optimal wellness at a transparent and affordable cost.

JOB TITLE: Population Health Specialist

REPORTS TO: Vice President, Population Health

The following statements reflect the general duties, responsibilities and competencies considered necessary to perform the essential functions of the job and should not be considered as a detailed description of all the work requirements of this position.

POSITION SUMMARY:

The Population Health Specialist is responsible for outreach to patients with gaps in chronic disease management and preventive care. This role serves to support health status improvement through access to services, education, wellness support and reinforcing the importance of the patient/primary care provider relationship.

RESPONSIBILITIES:

• Provide telephonic targeted outreach to identified patients. Includes current and new patients.

• Utilizes EMR Systems, registries, managed care data, opportunity reports, payer portals and other data as available to validate gaps and conduct outreach activities as assigned.

• Maintains tracking of outreach and gap closure.

• Using EMR tools, initiates outreach via EMR portal messages, phone calls, and/or via letters.

• Updates EMR Systems and payer portals as appropriate.

• Supports supplemental data submission process for plans without electronic supplemental feeds.

• Collaborates with Practice Transformation Team on the identification of quality care improvements.

• Shares findings of identified concerns/issues/quality care improvements related to gap closure, ordering process and documentation of care with quality team so that they may be addressed and/or implemented efficiently and effectively.

• Collaborates with practice staff and managed care partners to provide additional information and coordination of practice level phone calls.

• Performs special focused projects/audits as assigned.

• Investigation of community resources/assistance needed for patient population; ensure an agency guest and/or information is available monthly to support the development of the material provided to the clinics.

• Outreach to outside clinics and health systems for results and quality data needed for improvement of practice scores.

• Perform quarterly quality measure audits to ensure practices compliance with documentation requirements.

Qualifications

• Required High School Diploma or equivalent

• eClinical Works experience preferred

• Preferred Completion of an accredited Medical Assistant program or LPN, EMT, ER Tech, or equivalent of education and relevant experience.

• 2 years of relevant experience Minimum of 2 years of experience as a medical assistant in an outpatient setting or a primary care setting

• Ability to communicate in English and Spanish, both orally and written.

• Possesses basic knowledge of target populations' ethnic and medical needs.

• Strong interpersonal and communication skills; the ability to demonstrate empathy and cultural sensitivity.

• Ability to relate to patients, community organization workers and representatives.

• Ability to work independently, works with medical and mental health professionals in a multi-disciplinary team.

• Business and personal computers, and standard software applications. Excel a must.

SALARY: Commensurate with experience

MORE INFORMATION: This is an exempt position.