The Population Health MA functions as an extension of all clinical teams and supports Revere Health's Value Based Care goals. This position will also assist with Telehealth appointments, provide outreach to patients to schedule appointments, review medications, discuss post hospital needs, facilitate needed testing, and proactively find solutions to patient's needs. Considers patients social needs and barriers and refers to appropriate assistance as necessary. Works with team to facilitate after hours calls for patients receiving remote monitoring of vital signs and provides clinical assistance to these patients when appropriate and based upon defined practice standards. Maintains patient records and other information. Administers medications as ordered. Assist with new employee vaccinations and testing. 

Essential Job Functions

• Independence and sound clinical knowledge and skills.
• Reviews patient registries and other data sets to identify gaps in care, disease specific screenings, and basic preventative health screens. Communicates to patient and/or clinic staff to ensure timely closure of identified gaps.
• Professional in all communications with the ability to explain processes and educate staff and patients is a vital aspect of this position. Provides courteous and friendly service to all patients and contributes to a positive work environment.
• Collects and tracks monthly, quarterly, and annual process improvement/quality measure data.
• Conducts analysis of data in collaboration with a variety of care teams to assist in identification of improvement activities. Presents data collected in an organized format to facilitate analysis and identification of improvement opportunities.
• Accesses daily reports to identify patients hospitalized, discharged, and treated in the Emergency Department (ED). Provides follow up communication to the RN Navigators and care team. Tracks provider outreach to patients discharged from the ED. Aids with care coordination, facilitates communication between patients, caregivers, and providers, helps to addresses barriers to care, and promotes optimal allocation of resources.
• Provides information to patients and families regarding community resources, medication assistance, and other healthcare needs.
• Assists patients with scheduling, ordering lab work, and/or testing that may be needed for a chronic disease as defined in the organizational standard protocols.
• Provides outreach to patients as they transition through multiple healthcare settings. Completes Transition of Care follow up for patients discharged from an inpatient setting. Ensures patient/caregiver understanding of discharge instructions and completes medication reconciliation.
• Supports patients to make them successful while following the written plan of care as indicated in the discharge plans and ambulatory care plan. Encourages patient to use self-management tools as provided.
• Requires some after-hours call.

Minimum Qualifications

• Current Certified Medical Assistant (CMA)
• Experience with medication reconciliation required.
• Knowledge of discharge planning, transitions of care, and community resources preferred.
• Minimum of two (2) years’ recent experience in a healthcare setting required. Primary care experience preferred.
• Experience and knowledge of electronic health records required.
• Knowledge of medical terminology, CPT and ICD-10 codes required.
• Ability to communicate effectively and maintain cooperative relationships with providers, staff members, patients and the medical community. Ability to employ tact, diplomacy and compassion with all types of people.
• Must have strong organizational skills and attention to detail. Strong research and analysis skills highly preferred. Must successfully function in a fast-paced, service-oriented environment.
• Must be detail-oriented, a self-starter, possess ability to set priorities, and function as part of a team. Possess ability to use good judgment, always maintaining confidentiality.
• Possess and maintain computer skills to include working knowledge of Word, Outlook, Excel, and the ability to learn other software as needed. Experience with data analytics and quality metrics preferred.