Population Health Advocate-SCP-Charleston

Job Summary

The emphasis of this position is on assisting the health center staff in promoting patient health through education, case management, and population health management using patient registries. The role involves outreach for health/wellness and disease management, supporting healthy lifestyle choices, and performing other clinically-based activities.

Responsibilities

• Provide health-coaching and consultation services to patients, within state licensure scope of practice requirements.
• Conduct health risk assessments, introduce case management services, identify and address barriers to treatment adherence, and educate members about healthy lifestyle choices within state licensure of practice requirements.
• Collaborate with patients to establish goals and provide ongoing support to members so they strive to make and sustain healthy lifestyle choices.
• Provide participants with educational materials and collaborate with primary care health center staff and providers to obtain specific and current health information related to the member's plan of care.
• Review data from various sources to assist in identifying co-morbid conditions, hospitalizations, prescriptions, and other factors that could impact the health of the patient. Use data to identify problems, set goals, plan interventions, and determine overall health status within the scope of practice.
• Aid in care coordination which may include obtaining test and referral results and communicating with various entities including community organizations, health plans, health facilities, and specialists. Proactively address patient needs through population health management.
• Create and manage patient registries that include care considerations for chronic disease management and preventive care. Assist the operations team in collecting clinical data for NCQA accreditation, meaningful use, and insurance-sponsored PCMH projects.
• Proactively address patient needs through population health management.
• Effectively communicate with all patients with specific attention to the vulnerable patient population. Document all activities as outlined in the Valley Health Policy Manual.

Qualifications

• High School Diploma or Equivalent; degree in Medical Assisting or Nursing preferred.
• Must possess a working knowledge of Medicaid/Medicare, adult learning and behavior change principles, chronic illnesses, co-morbidities, and disease management, and community-based resources.
• Skills include excellent verbal and written communication skills, telephonic interviewing skills, computer skills, and prioritization and organizational skills.
• Must be able to prioritize and target interventions designed to support long-term behavioral change within state licensure scope of practice requirements.

Working Conditions

• Work is sedentary in nature; however, the ability to stand and/or walk for periods of one hour intervals; stooping, bending, reaching, lifting approximately 25 pounds is required.
• Work is repetitive in nature and requires concentration and constant technical attention to accuracy and detail for extended periods of time.
• Conveys a professional and positive image and attitude regarding the health center and organization.
• Develops good rapport with colleagues, patients, and their families.

Hours

Monday - Friday 8:00 - 4:30