Population Health Specialist

ESSENTIAL DUTIES AND RESPONSIBILITIES

• 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.
• Affiliate 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.
• Complete special projects as assigned.

EDUCATION AND EXPERIENCE

Requires a bachelor’s degree in public health, social work or health related field. Master’s degree preferred.

SKILLS

• Ability to use MS Office, especially Excel spreadsheets.
• Ability to analyze and interpret data.
• Ability to learn and implement IT applications for population health.
• Customer service skills, ability to interact with patients from diverse backgrounds.
• Strong communication skills, ability to effectively communicate with patients, clinical staff, and external stakeholders, such as health plans and government officials.
• Ability to multi-task in fast-paced environment.
• Flexibility, able to work independently.
• Strong critical thinking, organizational and attention-to-detail skills.
• Ability to present data in oral or written report form.

PREFERRED SKILLS

• Experience with electronic health records and other health IT tools.
• Experience in health care setting.
• Experience with motivational interviewing.