JOB CONTENT

Position Summary:

(Overall purpose of this position)

• Develop, implement, and evaluate population health efforts.
• Address care gaps with evidence-based, best practices outreach programs.
• Initiate and execute patient outreach to improve screening rates and health of patient population.

Essential duties and responsibilities which must be performed in order to carry out the position purpose summarized above:

(The following description is a general representation of the key duties and responsibilities of this position. Other duties may be assigned, as required.)

• Identify care gaps with patients and work with quality and care team members to address them. Care gaps could include screenings for cervical cancer, colorectal and breast cancer, routine examinations for specific populations such as well child checks for children, adolescents and required and recommended immunizations, diabetes control and stabilization.
• Work with payors reports and close their care gaps (United, Medicare).
• Update Health Maintenance from Care Everywhere for specific metrics.
• Document patient contact and health maintenance in Epic and close referrals.
• Utilize patient reports and lists and update databases as needed.
• Effectively utilize programs including Acuere and workbench registries within Epic.
• Run reports in Epic Workbench and Acuere to identify patients in need of screenings, to measure progress of quality metrics. Place bulk orders using Epic Workbench.
• Initiate and execute outreach projects that include: patient phone calls, MyChart messaging, letters and postcards, marketing, community outreach meetings, group medical appointments, patient education.
• Work on FIT project (sending out FITs, follow up phone calls, placing bulk orders, assembling FITs and sending them to sites/patients).
• Schedule patient appointments.
• Assure that scanned documents of outside procedures are scanned properly into Epic, and update the records if needed.
• Attend team meeting to present monthly data and gather team’s comments and ideas as needed.
• Complete chart audits as needed.
• Provide support to patient care teams; maintain updated educational and health screening materials.

• Assist in community events as needed.

• Assist in developing patient education materials.
• Work with Report Developer (Ed) on reports for Quality.
• Provide data for grant reports.
• Prepare weekly productivity reports.
• Work on CPC:

• Work with quarterly CPC reports to identify patients who need care management and add them to the team lists.
• Extract CPC data from reports, and create interim notes.
• Interact with nurses on CPC.

• Analyze monthly UDS reports for team meetings as needed.
• Taking meeting minutes as requested.
• Interface with IT on quality projects.
• Other duties as requested

Qualifications:

• Specific knowledge, training or skills required to perform the duties of this position. Specific concepts, courses, training programs or required certifications:

(To perform this position successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skills and abilities required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.)

• Previous experience in the health care field preferred.
• Medical knowledge sufficient to understand health subjects.
• Ability to manage competing priorities.
• Customer service or patient contact experience.
• In-depth computer skills: Microsoft Office Suite; data analysis and database management; EMR (Epic).
• In-depth written and oral communication skills: stand-up presentation skills.
• In-depth emotional intelligence: demonstrated self-awareness, accurate self-assessment, sensitivity and empathy, openness, reliability and consistency.
• Project management skills.
• Knowledge of public health and underserved populations.
• Cultural competence in dealing with patients.
• Demonstrated ability to work in a multicultural environment; Spanish language skills preferred.
• Driver’s license and insurance in Ohio for local travel.

Essential Physical Demands and Working Environment:

(The physical demands and work environment described below are representative of those that must be met by an employee to successfully perform the essential functions of this position. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.)

• Ability to see, communicate, hear and utilize electronic communication devices.
• Office work environment.

Previous experience that is necessary background to qualify for this position:

• Healthcare experience preferred

REPORTS TO AND EVALUATED BY: Population Health Manager