Population Health Coordinator

SUMMARY

The Population Health Coordinator provides support and oversight for the CCAH, Medi-Cal and Aspire Health Plan (AHP) patient populations. Perform comprehensive tracking and follow-up of patients in need of care establishment with the clinic and in regards to ensuring timely and appropriate follow-up screening. Serve as primary liaison for patients, medical assistants, physicians, and population health staff in regards to the populations served. Organize and assist educational outreach and provide updates regarding progress and procedural changes. Promote awareness of current CCAH and Aspire metrics, purpose and initiatives.


ESSENTIAL DUTIES AND RESPONSIBILITIES

Includes but not limited to the following:

• Work cohesively with various departments throughout Cypress as well as entities including but not limited to Health Information Technology (HIT), Salinas Valley Health Clinics (SVHC), Salinas Valley Hospital (SVH), Central Coast Alliance for Health (CCAH), Aspire Health Plan (AHP) and other at-risk programs.
• Contacts, orients and educates new and established patients about SVHC PrimeCare; initiates care plans; provides educational information, updates patient history, obtains necessary medical release information, and updates continuing care requirements.
• Develop interdisciplinary care plan (chart) and other case management tools to ensure new and established patient charts are accurate and up-to-date with current and upcoming care gaps.
• Ensure proper documentation and health related forms for CCAH and Aspire are within the chart prior to the patients scheduled visit; resolving issues that could affect the care progression; fostering clinic team support; providing education to others regarding the case management process.
• Maintains concise documentation in patients' electronic medical records (EMR)
• Scheduling and rescheduling all routine and non-routine medical services for assigned patient population.
• Prepare and generate appropriate medical records; generate EMR reports for CCAH and AWV (Annual Wellness Visit) four days in advance according to pre-visit planning guidelines.
• Update CCAH checklist and identify patient care gaps; prepare necessary patient folders for scheduled office visit.
• Responsible for importing newly enrolled CCAH members monthly to CCAH performance Tracking workbook; ensuring prompt contact with new patient population and scheduling of IHA and/or new patient physical; generating visit worksheet and documentation of identified care gaps.
• Follows the CCAH protocol for newly linked members to ensure provider compliance.
• Responsible for importing newly assigned Aspire Health plan patient population in the Aspire Performance Tracking workbook; and follows Aspire protocol for newly assigned members.
• Responsible for implementing and timely mailing out of monthly Campaigns by following the Monthly Campaigns schedule; Generate call lists and Mailers focused on ensuring streamlined communication and awareness of patient healthcare needs.
• Perform a variety of administrative duties including but not limited to: answering phones; faxing and filing of confidential documents; and basic Internet and email utilization.
• Analyze, develop and implement improvement activities to increase both provider performance and patient compliance for chosen quality measures.
• Responsible for continuously monitoring quality metrics and care gaps by validating quality measures to ensure data accuracy in order to meet goals.
• Ensuring timely and accurate reports to ensure follow up regarding defined quality and metric year end targets.
• Identify data collection procedures necessary to provide more effective and efficient care while also predicting utilization and other metrics tied to quality of care.
• Leads and participates in special projects, as directed; and performs other duties as assigned.

• Maintains an expertise of the outpatient practice operations
• Maintains a high degree of knowledge in
  • The care management process
  • Working knowledge of the concepts of Medi-Cal managed health care and Medicare Advantage
  • Ability to manage assigned program, including identifying issues and resources, establishing priorities, delegating and coordinating work and assisting with program development
  • Ability to evaluate medical records and other health care data
  • Ability to plan, organize and lead data collection activities
  • NCQA standards and guidelines for Patient-Centered Medical Home level three recognition

EDUCATION and/or EXPERIENCE

The employee performing this position is expected to hold a High School diploma and have at least 3 years of related healthcare experience involving quality improvement, healthcare quality practices, as well as medical clinic administrative or medical scheduling experience preferred. Three years direct experience in ambulatory care practices in various specialties preferred. Associates degree preferred.

PREFERRED

Bilingual may be required at certain clinics or during certain shifts.

SUPERVISORY RESPONSIBILITIES

This job has no supervisory responsibilities.

KNOWLEDGE

The jobholder must demonstrate current competencies applicable to the job position.

• Excellent customer service
• Problem resolution skills
• Critical thinking skills and ability to analyze datasets
• Effective verbal and writing skills
• Microsoft Office knowledge (Word, Excel, and Outlook)
• Demonstrates customer-focused interpersonal skills and interacts effectively with practitioners, the interdisciplinary healthcare team, community agencies, patients, and families who may have diverse opinions, values, and religious and cultural ideals.
• Demonstrates ability to work autonomously and be directly accountable for results
• Demonstrates flexibility
• Exhibits capability to influence and negotiate individual and group decision making
• Possesses skills to function effectively in a fluid, dynamic, and rapidly changing environment
• Displays proven ability to positively influence behavior and outcomes

CONDITIONS OF EMPLOYMENT


Proof of identity and legal authority to work in the U.S. is a condition of employment. Cypress Healthcare Partners/Salinas Valley Health Clinics will not sponsor applicants for work visas.

The range displayed on this job posting reflects the target for new hire salaries for this position.