Population Health Specialist

Population Health Specialist

The Population Health Specialist at North Shore Community Health is responsible for driving improvement in designated population health and quality metrics using available data from reports and from patient health records. Key focus areas of the role include engaging in patient outreach as well as providing education to and collaborating with the patient's primary care team members and other health center colleagues. The Population Health Coordinator will serve as a point person on various initiatives related to health center performance metrics. These include metrics such as those focused on patient care, patient engagement, care coordination, risk adjustment/coding and other metrics related to our accountable care organization (ACO).

North Shore Community Health (NSCH) is a highly accomplished community health organization that prides itself on its compassionate approach to serving the surrounding communities with comprehensive and culturally sensitive care. With a strong commitment to excellence, NSCH provides:

• Comprehensive primary care.
• Dental services.
• Behavioral health care.
• Care management.
• Pharmacy services.
• Substance abuse disorder treatment.
• Nurse care management.
• Insurance enrollment assistance.

NSCH operates service sites at Gloucester, Peabody, and Salem Family Health Centers, ensuring convenient access to care. Additionally, NSCH extends its reach through school-based health centers within the Salem and Peabody School Districts. NSCH collaborates with Bentley Academy, Collins Middle School, Horace Mann School, Bates Elementary School, and the Peabody Learning Academy for behavioral health services.

As a community-based safety net healthcare provider, NSCH actively encourages diversity and welcomes staff members who reflect the rich tapestry of our communities. We highly value the contributions of our team members and offer a wide range of perks and comprehensive benefits. These include health and wellness benefits, tuition reimbursement, loan forgiveness opportunities, and other appealing benefits.

We believe in supporting our employees from day one, and all eligible staff members can take advantage of these benefits right from the start of their employment at NSCH. We aim to foster a supportive and rewarding environment that empowers our team members to provide exceptional care to our communities.

North Shore Community Health's mission is to build healthy communities by providing exceptional care to all.

Healthy People | Vibrant Communities

Accountability: We take our responsibility to ourselves, each other, and the NSCH Community very seriously. We understand our individual roles, and positions of power with respect to how others perceive our roles and actions. We hold ourselves accountable when we make mistakesacknowledging the error, owning it, taking corrective actions, and moving forward. We follow through on what we commit or resolve to do.

Integrity: Integrity is the foundation of healthy relationships. We are committed to the highest ethical standards: honesty, fairness, respectfulness, and trustworthiness. We are honorable and respectful in dealings with others, and we strive to deal honestly, fairly, and in a respectful, ethical, and trustworthy manner when in agreement or disagreement.

Empathy: Empathy is a deep appreciation for another's situation and point of view, which is the basis for the golden rule and our intrinsic sense of justice. We strive to bring empathy into our interactions with each other and with our patients.

Courage: We see courage as the strength of character to stand up for our convictions and belief system. To have courage is to have the fortitude to take risks and to extend one's behaviors, actions, and thoughts beyond one's comfort zone. We appreciate that courage is often required to compromise. Courage is a state of mind to face adverse, difficult, and challenging situations with confidence and positive energy.

Respect: NSCH holds its patients in the highest regard. We provide care that is respectful of and responsive to individual patient needs and values. We take the time to listen to concerns, understand what is important, and provide appropriate solutions and care. We do this through coordination and integration of care, collaboration, and teamwork.

Commitment: NSCH is committed to the health and well-being of its community, patients, and staff. We demonstrate this commitment by constantly striving to align our actions with our mission, vision, and values.

We, North Shore Community Health (NSCH), are an equal employment opportunity employer. Our goal is to have a diverse workforce representative of all people, at all job levels, in the organization. We do not and will not make any personnel decisions (like recruiting, hiring, job assignments, and promotions) based on age, color, national origin, citizenship status, physical or mental disability, race, religion, creed, gender, sex, sexual orientation, gender identity, gender expression, genetic information, marital status, status with regard to public assistance, veteran status, or any other characteristic protected by federal, state or local law.

Collaborate with Quality Improvement Manager, ACO and patient care team members to help meet annual population health and quality improvement goals.

Utilize online data management systems such as DRVS, Arcadia & Healthy Planet and/or collaborate with Data Analyst to create patient registries, validate patients' empanelment status, and identify/resolve patient quality and coding gaps.

Collaborate with clinical and operations team members to create sustainable workflows that help drive NSCH's QI plan forward.

Based on patient registries or via other systems, track patients due for preventive care, chronic disease management, follow-up of abnormal results, or other health care services to identify gaps in care.

Devise new approaches to drive successful outreach to patients with patient needs and efficiency at center of efforts.

Conduct patient outreach through a variety of means (phone, text, e-mail, mail) in order to engage patients in care or to follow-up with patients in the case of missed appointments/services.

Collaborate with NSCH's marketing team to provide quality related material for community events, patient waiting areas, & social media.

Create and distribute resources to help educate patients and staff on QI initiatives (posters, tip sheets, etc.)

Ensure timely and accurate documentation of outreach or other relevant information in the EHR per NSCH policies.

In collaboration with the QI manager, develop systems to track performance for each priority measures and determine what to prioritize each quarter

Assist with reviewing registries of patient ED and hospital visits and facilitating post-hospital care as needed.

Participate in empanelment/attribution/patient engagement activities in collaboration with/as needed by the Ops team

Conduct chart reviews and review other sources of medical record data to identify information relevant to quality measures and reconcile patient records.

Utilize standard workflows to conduct, track, patient outreach and to meet team KPIs

Collaborate with the referrals team as needed to ensure records related to gaps in care are obtained.

Assist with resolving patient coding gaps through patient outreach and care team prompts based on available reports.

Present key population health and performance data and updates to care team members and collaborate on best follow up tactics to improve overall performance at the monthly site meetings

Work with managers and care teams to develop and monitor systems to ensure quality and coding requirements are being addressed successfully.

Communicate with care teams and other relevant staff to provide updates and get input on outreach, quality/coding initiatives as needed to help ensure quality and coding gaps are addressed.

Work closely with ACO Performance Improvement team and other ACO and health center staff to monitor and to optimize quality of care, clinical workflows, and accurate capturing of quality/coding data.

Attend monthly quality improvement committee, ACO/population health and health center team meetings as needed to play a role in other relevant quality efforts across the health centers.

Attend ACO, quality, improvement or other trainings as needed.

Collaborate with QI manager to develop training plans for any new population health team members

Other duties as assigned

Requirements

Experience in a community health center setting and/or related experience in health/human services, social services agency preferred.

Complies proper paperwork procedures, prompt follow-up communications and departmental policies.

Demonstrated strong communication skills with individuals and groups.

Spanish or Portuguese skills are a plus.

Strong computer skills and ability to quickly adapt to using an electronic health record and Microsoft Office applications.

Strong analytical, problem solving and planning skills.

Ability to successfully prioritize multiple projects on an ongoing basis.

Strong ability to think creatively

Self-motivated and self-directed to work independently as well as ability to engage with various teams across the organization.

Additional desirable qualities include enthusiasm and passion for helping patients, and empathetic nature

Ability to leads guild-specific training sessions and workgroup