Population Management Coordinator

Optum; Easton Center (MA); Hybrid; USD 57,308,000 - 103,155,000; Full time

Job summary

Atrius Health, part of the Optum family, seeks a Population Management Care Facilitator to support chronic disease management and preventive care in a hybrid clinic setting in eastern Massachusetts. You will organize outreach, coordinate with care teams, and drive adherence to care plans using data-driven workflows.

The role requires reviewing charts, identifying care gaps, and leading population health initiatives while maintaining high-quality patient interactions in a fast-paced environment.

Qualifications

• Experience supporting clinical or administrative workflows in health care.
• Ability to translate quality metrics into actionable actions.
• Strong organizational and communication skills.

Responsibilities

• Coordinate outreach efforts and organize patient calls to avoid duplication.
• Collaborate with care teams, nutrition, social work, and insurers as needed.
• Review charts for care gaps and initiate appropriate interventions.
• Contact patients and staff to relay care plan information and document in EMR.
• Research patient data and recommend indicated clinical procedures.
• Lead monthly population management panel roster reviews for physicians.

Skills

Customer service

Data interpretation

Communication

Education

High School diploma or equivalency

Tools

Microsoft Office Suite

Job description

Explore opportunities with Atrius Health, part of the Optum family of businesses. We're an innovative health care leader and multi-specialty group practice, delivering an effective, connected system of care for adult and pediatric patients at 28 practice locations in eastern Massachusetts. Our entire team of providers (physicians, PA/NPs and ancillary clinicians) works collaboratively with a value-based philosophy within our group practice as well as with hospitals, rehab and nursing facilities. Be part of our vision to transform care and improve lives by building trust, understanding and shared decision-making with every patient. Join us and discover the meaning behind Caring. Connecting. Growing together.

As a member of the clinical care team, is responsible for supporting efforts to meet Atrius quality goals by facilitating both routine preventative care and ongoing chronic disease management for primary care patients. Works in a matrix function with overall direction from clinical and administrative leadership at the IM Service Line and the Performance Excellence department, and daily supervision from clinical and administrative leadership at the IM practice site. Identifies and articulates opportunities for work flow changes to improve quality of care related to the organizational strategic quality goals. Understands complex characteristics of the quality metrics and translates the metrics into actionable workflows for the clinical practice. Serves as the organizer and driver of population management outreach work at the site, and plays a key support role for onboarding patients to the practice. Navigates data for large populations of patients to identify recommended clinical care opportunities and subsequently organizes and prioritizes action items, including allocating tasks to the appropriate member of the care team and ensuring efforts are coordinated and avoid duplication.

Manages a high volume of patient outreach for patient populations with chronic illnesses (e.g., diabetes, hypertension and cardiovascular disease) as well as for primary care patients needing preventative screening tests within the broader patient population. Builds relationships with patient in order to assist the primary care team in developing an effective and accessible plan of care and ultimately tracks adherence to this plan of care.

Note: The role of Population Management Care Facilitator involves complex and detail-oriented responsibilities, the ability to understand and articulate clinical terms and processes and the ability to interact with patients and clinicians about preventative health and chronic disease management.

Primary Location: 21 Bristol Dr South Easton, MA. Occasional coverage also required at 152 Dean Street, Building 3 Taunton, MA & 31 Pine Street Suite 300 Norfolk, MA

Hours: Monday - Friday 8am - 5pm

This position follows a hybrid schedule with two in-office days per week.

Primary Responsibilities

• Coordination/Facilitation/Organization of outreach efforts
  • Serves as a central organizing point within the site for population management activities. Organizes which patients need calls and coordinates who the appropriate person to make the call would be (typically medical assistants or medical secretaries) in an effort to avoid multiple calls to the same patient
  • Collaborates with primary care case management, internal and external specialists, nutrition, social work and insurers as needed
  • Independently review charts, identify or verify care gaps, provide appropriate intervention (e.g. onboarding, outreach, communication to clinician, etc.)
  • Independently contacts patients, clinical and administrative staff and external organizations to gather and relay clinical and care plan information
  • Researches individual patient's clinical information and recommends clinical procedures and tests that are indicated based on standard clinical guidelines
  • Conducts examinations of the clinical record to determine if outreach for identified 'care gaps' is appropriate given patient's current medical status
  • As needed, places routine lab orders to assist in ongoing clinical management of patients with chronic diseases
  • Performs high volume of daily patient outreach calls, mailings and MyHealth messages in regards to lab tests, appointments and other chronic care recommendations made by the primary care team. Documents details of outreach attempts into patients' electronic medical record to ensure coordination of care
  • Ensures that all necessary documentation of external medical care is documented into the patient's Atrius Health electronic medical record
  • Tracks patient adherence with scheduled appointments, labs, referrals and prescription compliance
  • Monitors patient adherence to treatment recommendations and works closely with Clinical Pharmacist and Physician to identify cost saving medications for optimal medication compliance to achieve treatment goals
  • Coordinates and leads monthly chronic disease management panel roster reviews for primary care physicians
• Data Management
  • Manages information flow of Atrius Health Quality metrics between leadership, clinicians and staff at the site
  • Conducts regular basic data analyses relevant to site's specific goals and initiatives
  • Prepares Excel spreadsheets and PowerPoint slides relevant to site's performance on quality metrics
  • Actively involved in practice site's population health initiatives and projects
  • Interacts with appropriate internal and external parties to gain an understanding of factors that affect the quality performance data for their site
  • Serves as source of information and clarification for most questions related to quality metrics and provides guidance in understanding the data to members of the care team (physician, MA, leadership, etc.). Usually refers complex questions to site leadership or central quality department
  • Helps to ensure the integrity and accuracy of the data, notifies Quality Department or site leadership of any inconsistencies in the data so that the aforementioned person(s) can resolve the issue with the appropriate resource
• Project Coordination
  • Independently evaluates metrics and potential courses of action and presents recommendation to site leadership. Advocates to local management for development of initiatives to improve point of care processes related to population management/quality.
  • Trains new clinicians and staff on the specifics of the quality metrics and workflows directly related to improving care/metric performance
• Other
  • Attends required monthly population management meeting to learn from other population management coordinators around the organization
  • Performs other duties as assigned

You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.

Years of post-high school education can be substituted/is equivalent to years of experience

Required Qualifications

• High School diploma or equivalency certificate (e.g. GED, HiSET, TASC Test) from an accredited institution or governmental unit
• Skills and experience typically acquired through 1+ years (one of which is calculated from degree) in a: clinical business support, or clinical research, or ambulatory care setting, or customer service business.
• Ability to work on Site at the required locations (South Easton, Taunton, Norfolk) at least twice per week

Preferred Qualifications

• Training or experience in population health management
• Knowledge and understanding of medical terminology
• Proficiency in Microsoft Office Suite

Working Condition / Physical Demand

• Busy medical/clinical office environment with frequent deadlines and interruptions

Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. In addition to your salary, we offer benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with us, you'll find a far-reaching choice of benefits and incentives. The hourly pay for this role will range from $20 - $36 per hour based on full-time employment. We comply with all minimum wage laws as applicable.

At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone-of every race, gender, sexuality, age, location and income-deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes - an enterprise priority reflected in our mission.

UnitedHealth Group is an Equal Employment Opportunity employer under applicable law and qualified applicants will receive consideration for employment without regard to race, national origin, religion, age, color, sex, sexual orientation, gender identity, disability, or protected veteran status, or any other characteristic protected by local, state, or federal laws, rules, or regulations.

UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.