Job Description

Essential Job Functions

Under the direction of the Population Health Manager:
• Identify patients who have been out of care and coordinate with Site Ops teams to inreach for appointments with PCP or medical team members
• Identify patients who are due for Annual Wellness Visits and facilitate scheduling appointments
• Identify care gaps and contact patients to complete outstanding orders as well as specialist office for notes documenting gap closure
Operational support for Population Health Activity, including but not limited to reviewing Remote Patient Monitoring data and submit qualifying encounters to Billing.
Administer Health Risk Assessments and SDOH screenings.
Assist patients in troubleshooting device and connectivity challenges, while keeping them motivated to regularly use remote health devices and to improve health.
Support patients in a variety of settings, including in-clinic, and in patient homes, either in person or using virtual visits (e.g. over phone or video calls, text messaging, emails.).
Maintain expertise in frequently used technology for patient care, including video platforms, smartphones, and remote patient monitoring devices.
Support program development and continuous improvement, such as developing educational materials (including handouts and videos), and improving policies and procedures, and contributing to data about program performance and patient experience.
Document patient care activities in Electronic Health Record (EHR).
Support care team in engaging and empowering patient to improve their health.
Collaboration within AHS sites and entities outside of AHS.
Represent AHS in community forums and meetings as needed.
Provide clinic support as needed, including:
• Schedule appointments; answer patient calls as needed.
• Check-in and check-out.
• Provide interpretation support.
• Provide basic nutrition and health counseling.
• Other duties as assigned by the supervisor.

General Agency/AHS Duties

Fosters an environment that promotes trust and cooperation among clients and staff.
Enforces clinic policies and procedures, including maintenance of client confidentiality under HIPAA privacy rules, to ensure that the principles of AHS are implemented.
Plays an active role in planning organization-wide activities such as AHS general membership meetings, fundraisers, special clinic days, and other events.
Participates in general membership meetings, fundraisers, and other public events, as required.
Participates in outreach activities, agency advocacy, and serves on ad hoc committees, as requested.
Attends AHS staff retreats and Board of Directors meetings, as required.
Participates in agency-wide quality improvement program processes and performance improvement teams to ensure excellence in the quality of services provided across the agency.

Knowledge, Skills & Abilities

• The relationship between advocacy and improving the health of the Asian community.
• Cultural, socioeconomic and political factors affecting health in immigrant and refugee Asian communities.
• Health, social services, and community resources/leaders in at least one API community.
• Leading and working with diverse staff and community members respectfully and collaboratively.
• Innovative, cooperative, and collaborative problem-solving.
• Planning and coordinating small-medium scale projects and events.
• Strong interpersonal and communication skills bother oral and written.
• Organizing and engaging immigrant communities in education and advocacy activities.
• Proficiency in or ability to learn English and Asian language word processing.
• Ability to work under pressure and handle multiple tasks.
• Ability to exercise good judgment.
• Ability to work independently with minimal supervision.
• Available to work on weekends and evenings as needed.
• Decisions have a broad impact on a patient’s experience at AHS.
• High level of concentration required coordinating multiple program tasks, problem-solving with external organizations, and coordination with other departments and programs of the entire organization.

Minimum Qualifications

A bachelor's degree and ​two​ years of work-related experience in a health setting -OR-
A high school diploma and four years of relevant work experience
Ability to speak, read, and write in a high proficiency level in an Asian language

Preferred Qualifications

Preferred Bachelor’s degree majors: health, social service, or other closely related fields
Preferred experience working in the community health field