Job Description

The Population Health Coordinator works directly with patients on population health programs to improve patient care. The coordinator also implements clinical data activities, and performance improvement and population health activities across Ambulatory Care, Emergency Department and Inpatient settings. They collaborate with stakeholders to gather data, run analytic reports, and interact directly with patients to improve their health. This includes meeting patients to discuss specific program goals, reviewing patient charts to identify gaps in care, and completing patient text message and telephone campaigns.

1. Implement population health programs as assigned, including, but not limited to:
   a) The Prescription Helper program, sending targeted text message reminders and phone calls to patients who are overdue for refills, and providing assistance to patients enrolled for enhanced support.
   b) The Recertification program, sending targeted text message reminders and phone calls to patients who need to renew their Medicaid coverage. providing direct support to patients in completing the online recertification process.
   c) The Pathfinder program, providing direct care transitions support and treatment linkage to patients with mental health or substance use issues.
   d) The Living Positive program providing direct support to patients with Viral Load suppression and our Undetectables initiative.
2. Collaborate with leadership, practice management, IT, and other stakeholders to collect and process data to improve the quality of clinical care.
3. Produce and distribute chase list reports to clinical and patient-facing teams to guide patient care and improve care quality and performance.
4. Review electronic medical records to confirm if patients are missing services or are navigating a transition in their care.
5. Support quality improvement projects in Population Health and Ambulatory Care services, and take responsibility for agreed actions.
6. Contribute to presentations, diagrams, and flowcharts for clinical staff.
7. Perform other duties at the discretion of leadership.
8. Attend scheduled department and division meetings and participate as appropriate.

Qualifications

• Associates Degree required, Bachelor’s Degree preferred.
• Two (2) years’ experience in healthcare quality settings with data or statistical analysis, data manipulation, and reporting is preferred.
• Experience working with patients with mental health or substance use issues preferred.
• Candidates must have good skills with Microsoft Excel, and have a basic knowledge of vlookup, pivot tables and formulas.
• Excellent written and oral communication skills
• Attention to detail and accuracy
• Excellent organizational skills