Population Health Specialist

JOB PURPOSE AND REPORTING STRUCTURE: Under the direction of the Director of Quality, the Population Health Specialist uses population health strategies to address the preventive and chronic care needs of the patient population. This includes analysis of patient health data to identify care gaps, outreach to patients to help them obtain needed services, and collaborating with clinic staff to ensure care coordination.

ESSENTIAL DUTIES AND RESPONSIBILITIES include the following. Other duties may be assigned.

• Work with heath plan partners to address preventive and chronic care needs of shared members.

• Analyze electronic health record (EHR) and health plan reports for care gaps, and create lists of patients for follow-up.

• Provide outreach to patients in need of preventive and chronic care services through electronic and print communication, including letters, text messages and phone calls.

• Help patients address barriers to care, such as transportation, income, insurance, through education and referral.

• Track outreach efforts in EHR and on spreadsheets as necessary.

• Follow up to ensure patients complete recommended care and documentation is recorded in the EHR.

• Use the EHR and other electronic tools to generate reports, improve clinical workflows and conduct patient outreach.

• Collaborate with clinical staff as needed to address patient care needs.

• Assist with health promotion and QI activities.

• Participate in committees and workgroups as required.

• Comply with federal, state and local regulations regarding patient confidentiality and HIPAA.

• Maintain technical competency and remain current in technology and changes in the industry.

• Complete and maintain all required paperwork, records, documents, etc.

• Follow and comply with all safety and work rules and regulations. Maintain departmental housekeeping standards.