Population Health Specialist

About the role

The Population Health Specialist is responsible for outreach to patients with gaps in chronic disease management and preventive care. This role supports health status improvement through access to services, education, wellness support, and reinforcing the patient/primary care provider relationship.

Responsibilities

• Utilizes the Medical Home model to provide targeted outreach to identified patients, including current and new patients.
• Validates gaps using EMR Systems, registries, health maintenance data, opportunity reports, payer portals, and other data sources.
• Conducts outreach via EMR portal messages, phone calls, and letters.
• Updates EMR Systems and payer portals as necessary.
• Supports supplemental data submission processes for plans without electronic feeds.
• Collaborates with the Practice Transformation Team on quality care improvements.
• Shares findings related to gap closure, ordering process, and documentation of care with the quality team.
• Prepares reports as required.
• Collaborates with practice staff to provide additional information and coordinate practice-level phone calls.
• Performs special focused projects and audits as assigned.
• Completes scheduled eye exams at ambulatory clinics, updates portal information, and ensures practices receive results for all patients.
• Travels to ambulatory sites to investigate community resources and assist patients.
• Outreaches to outside clinics and health systems for results and quality data needed for practice score improvement.
• Carries out quarterly quality measure audits to ensure practices comply with documentation requirements.

Requirements

• High School Diploma or equivalent.
• Minimum of 2 years of relevant experience and 2 years as a medical assistant in a clinical physician practice, a clinical nursing program, or 2+ years in a population health-related role.
• Experience in data entry.

Qualifications

• Completion of an accredited Medical Assistant program or equivalent of education and relevant experience.
• Certified Medical Assistant (CCMA) - NHA National Health career Association.