Population Health & Planned Care Coordinator
: Job Details :

Job DetailsJob Location 415 Columbia Rd - Dorchester, MA Position Type Full Time 30+ hours Education Level Not Specified Travel Percentage Negligible Job Shift Day Job Category Health Care DescriptionPosition Title: Population Health & Planned Care Coordinator Department: Quality Supervisor: Director of Quality, FQHC Status/Hours Per Week: Exempt / 40 hours Primary Function: The Population Health & Planned Care Coordinator requires a high degree of autonomy in analyzing and performing process improvements, patient outreach and workflows that result in facilitating quality improvements at the federally qualified health center (FQHC). The Coordinator must be able to work in a fast-paced environment, work with stakeholders, clinical, administration and behavioral staff while successfully managing multiple tasks, adapting to shifting deadlines and priorities. Duties & Responsibilities: By establishing quality assurance that promote customer satisfaction and positively impacting the quality performance of Upham's Community Care, the Coordinator is responsible for: •Patient population health outreach initiatives under the Primary Care Department. •Work with the Director of Quality to improve quality improvement initiatives that achieve targeted clinical and operational goals. •Facilitate the success of UCC's performance in its value-based payment model contracts. •Play a key role in working across administrative, clinical and operations departments in coordination with the Quality and change management team at the health center. •Lead clinical care team forums. •Handle quality data collection. •Work with the Director of Quality on special projects as assigned. •Provide leadership, operational support, and care coordination to support the health center's population health strategy to achieve the patient-quality measures and goals. •Oversee the work of clinical staff to ensure that the population health strategy is being implemented effectively and efficiently. •Maintain patient care database by entering new information as it becomes available; verifying findings and reports; and backing up data. •Prepare lists/reports in advance of care team meetings in order to ensure accurate and prioritized patient outreach lists using reporting workbench tool. •Monitor clinic's progress towards the ambulatory goals through the use of OCHIN EPIC EMR reports (RWB), EPIC chart reviews and business object tools. •Evaluate progress and measure intervention effectiveness monthly/bi-weekly with interdisciplinary team and reach out to primary care leadership if additional support is needed. •Develop and present data that summarizes progress on the quality goals to clinical staff. •Initiate contact with patients as needed, working proactively with the site leadership team to ensure access to health care services by identifying and removing barriers to care. •Train, re-train care team members and staff in quality improvement and planned care activities and use of Epic in relation to the quality reports and associated patient lists, and also perform ongoing training as needed. •Share best practices within ambulatory sites. •Assist with troubleshooting problems with reports and health care maintenance in EPIC. •Manage a vast array of quality measures from external stakeholders (e.g. C3, BACO). •Integrate UCC resources to increase patient engagement in their care (e.g. assisting patients with financial needs). •Manage day-to-day workflows related to clinical quality metrics and risk coding optimization. •Implement workflow changes in order to enhance performance on key metrics. •Serve as the point-of-contact to Community Partners involved in the health center's patient care through coordination and documentation of communication between Behavioral Health and Community Partners. •Serve as point-of-contact for overlap between the health center's electronic health record and other platforms related to value-based performance. •Update patient charts in the electronic health record with relevant care alerts and care plans. •Assist in the coordination of care management programs for assigned patients as necessary. •Attend meetings related to Accountable Care Organizations, Quality Improvement, OCHIN Electronic Medical Record System, and others as necessary and participate in committees, task forces, and teams working to improve health outcomes, clinical quality and patient safety. •Assist in coordinating the completion of SDOH form for patients at medical appointments. •Serve as intake and triage staff for patients requesting services from the Support Services team. •Perform other duties and responsibilities as directed or assigned. QualificationsMinimum Basic Knowledge: •Familiar with Epic EMR and Acadia (Population Health platform). •Health related degree preferred. Experience & Qualifications: •At least 3+ years of experience in community health/healthcare setting required. •Bachelor's degree in related field or equivalent relevant experience. •Strong analytical and computer skills required. •Excellent written and verbal communication skills and the ability to manage care team meetings. •Able to direct care teams on quality improvement efforts/proposed workflows. •Ability to maintain confidentiality, including appropriate disposal of confidential documents is required. •Experience in culturally diverse settings and passionate about community health services. •Strong interpersonal, organizational, and written and verbal communication skills. •Ability to meet deadlines, work comfortably in fast-paced work environment, independently and as part of a team. •Previous patient outreach experience preferred. Independent Action: Significant amount of independent decision making as required by duties of position, along with ability and willingness to work under direction of supervisor. Supervisory Responsibility: N/A Define Access Level to PHI: Level 2: Authorized to access patient demographic data with only minimal reference to treatment or diagnostic information as needed to function. Staff in this category level should confine the use of PHI to the minimum necessary required and should not access or read parts of the medical record not needed to perform assigned duties.