Population Health Coordinator: Elevate Care Quality

Greater Lawrence Family Health Center, Inc.; Massachusetts; On-site; USD 60,000 - 80,000; Full time

Benefits offered by this job

Tuition reimbursement

Comprehensive benefits

Growth opportunities

Job summary

Greater Lawrence Family Health Center, Inc. is seeking a Population Health Coordinator to join its care management team and help close care gaps through data coordination and outreach for patients with chronic illnesses and preventive screenings.

Under supervision, the PHC will organize pre-visit huddles, post-care follow-up, and proactive patient outreach, utilizing data systems like a data warehouse and Arcadia to identify gaps and improve quality within the PCMH framework.

Qualifications

• Must have 3 years’ experience as a senior medical assistant or 5 years of experience in a clinical setting.
• Bilingual (English / Spanish) required. Must be able to read and write English.
• Demonstrable experience working in primary care practice support/quality management roles.
• 1-2 years of greater working in primary care, clinic, population health role.
• Experience working in managed care highly desirable.
• Self-motivated and self-directed to work within a team and/or work independently.
• Strong analytical, problem solving, planning and prioritization skills.
• Excellent interpersonal skills required.
• Excellent verbal and written communication skills required.
• Basic working knowledge of Excel

Responsibilities

• Supports team based pre-visit planning activities and coordinates follow-up and loop closure
• Under the leadership of the AVP of Clinical Integration and Director of Population health, the PHC collaborates with Quality Improvement and ACO team members to help meet annual quality and risk adjustment goals
• Utilize online data management systems such as data warehouse and Arcadia to collaborate with Data Analyst to create patient registries, validate patients’ empanelment to our health center, and identify/resolve patient quality and coding gaps
• Based on patient registries, track patients due for preventive care, chronic disease management, follow-up of abnormal results, or other health care services to identify gaps in care
• Ensure timely and accurate documentation of outreach or other relevant information in the EHR
• Review registries of patient ED and hospital visits and coordinate with nursing team to ensure appropriate follow-up appointments are in place
• Communicate with care teams and other relevant staff to provide updates and get input on outreach, quality/coding initiatives as needed to help ensure quality and coding gaps are addressed
• Work closely with ACO Performance Improvement team and other ACO and health center staff to monitor and to optimize quality of care, clinical workflows, and accurate capturing of quality/coding data

Skills

Bilingual English/Spanish

Analytical skills

Communication skills

Teamwork / collaboration

Self-motivated / independent work

Tools

Excel

Job description

Greater Lawrence Family Health Center, Inc. is seeking a Population Health Coordinator to join its care management team and help close care gaps through data coordination and outreach for patients with chronic illnesses and preventive screenings.

Under supervision, the PHC will organize pre-visit huddles, post-care follow-up, and proactive patient outreach, utilizing data systems like a data warehouse and Arcadia to identify gaps and improve quality within the PCMH framework.