Job Description

Job Type
Full-time
Description

Southeast Primary Care Partners is seeking dedicated Population Health Outreach Specialists to join our expanding medical group and help improve health outcomes for high-risk patient populations through proactive outreach and care coordination. This position offers two levels of progression, based on qualifications and responsibilities.

Requirements

Level 1 Requirements:

• Current Medical Assistant Certification
• Minimum 2 years of patient-facing experience in clinical or care management setting
• Valid state licensure/certification as required

Level 2 Requirements:

• Licensed Practical Nurse (LPN) or Registered Nurse (RN)
• All Level 1 requirements plus additional responsibility for device monitoring/management for remote patient monitoring
• Preferred: 3+ years of care management experience

Core Responsibilities (Both Levels):

• Conduct proactive outreach for Annual Wellness Visits for Medicare and Medicare Advantage patients
• Assess and enroll patients in care management programs (RPM, CCM, Pharmacy Outreach)
• Monitor and close care gaps for preventive screenings
• Support medication adherence initiatives with pharmacy team
• Coordinate care transitions from ER to community setting
• Navigate patients throughout value-based programs
• Document patient interactions and care coordination in EMR
• Track and report population health metrics and outcomes

Additional Level 2 Responsibilities:

• Manage remote patient monitoring devices and data
• Provide advanced care coordination for complex cases
• Mentor Level 1 specialists
• Lead quality improvement initiatives

Required Skills and Competencies:

• Strong proficiency in EMR systems
• Excellent verbal and written communication skills
• Proficient in Microsoft Office Suite
• Strong organizational and time management abilities
• Problem-solving and critical thinking skills
• Detail-oriented with strong documentation abilities

Preferred Qualifications:

• Experience with population health management
• Knowledge of HEDIS/STARs measures
• Bilingual capabilities (English/Spanish)

Key physical and mental requirements:

• Ability to lift up to 50 pounds
• Ability to push or pull heavy objects using up to 50 pounds of force
• Ability to sit for extended periods of time
• Ability to stand for extended periods of time
• Ability to use fine motor skills to operate office equipment and/or machinery
• Ability to receive and comprehend instructions verbally and/or in writing
• Ability to use logical reasoning for simple and complex problem solving
• Ability to travel to multiple locations to support business needs as required

FLSA Classification: Non-exempt

Southeast Primary Care Partners is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability status, protected veteran status, or any other characteristic protected by law.

12/2024