Description

The PMC will manage Primary Care Provider (PCP) panels, assist patients to access targeted care, improve the quality of chronic care service delivery, assist medical providers in care management, manage the Universal Community Health Center population health management system, and participate in continuous quality improvement. Through the use of robust patient registries, this role will identify unmet care needs, and in collaboration with the health care team, target interventions to improve the health outcomes of patients. 

Requirements

•  Receive, review, and act on monthly panel reports to:
  • Monitor the assignments of patients into PCP panels
  • Assesses panel size against “right size” to determine PCP capacity to absorb new patients
  • Recommend to the medical director and/or management team to close or open provider panels according to panel capacity
  • Review issues with Medical Director, as needed
  • Reassign patients to other PCPs as appropriate
• Manage a monthly continuity report that determines continuity percentages for each provider, and adjust for vacation coverage schedules and other factors.
• Assign unassigned patients by reviewing appointment history (and possibly the clinical record) to determine appropriate assignment.
• Track patient status changes including death, transfers to other care, and make the change in the practice management system.
• Review and act on transfer of care requests, including:
  •  Patient-initiated PCP-change requests:
    • Facilitate discussion between and obtain approval from current assigned PCP and future PCP
    • Make PCP assignment changes in the practice management system/EHR
  • Provider-initiated PCP change requests:
    •  Obtain agreement of acceptance by the new PCP
• Track provider status changes (transfer, termination, sabbatical, medical leave, etc.) and:
• Evaluate impact on assigned panel of patients and scheduling
• Reassign panel to other clinic providers according to panel capacity
• Notify affected patients of new PCP assignment

Patient Care

• Update and maintain registry of patients, using a robust tracking system, that can follow patients based on PCP panel assignments or disease/condition.
• Enter data and manage the integrity of data entries for patient registries by conducting data cleanup, running periodic reports, and confirming accuracy of electronic registry records.
• Systematically review registries for target populations/panels to conduct predetermined interventions agreed upon by clinical team members.

Commitment to Quality

• Contribute to quality improvement efforts by providing feedback and progress reports to Site Improvement Teams on health status outcomes of panels. The PMC may also serve as a member of the Site Improvement Team.
•  Collaborate with other health care team members, such as health educators, to support individual or group-based interventions of care.
• Attend Quality Improvement meetings and other meetings that support Panel Management activities.
• Carry out the full array of patient-centered medical home (PCMH) duties as assigned based on the operational needs of the clinic.

General Office Duties

• Perform general office duties, such as scheduling appointments for patients, answering telephones.
• Greet and register patients arriving at the office or clinic in the appropriate electronic system.
• Contact medical facilities or departments to schedule patients for tests or appointments.

Qualifications & Competencies

• Demonstrated knowledge and experience managing patient databases and other computer software programs such as Excel, Google sheets, and practice management systems.
• Demonstrated knowledge of chronic care model, fundamentals of health education, and motivational interviewing.
• Self-driven individual with ability to work independently and exercise good judgment.
• Ability to work effectively with teams, demonstrating willingness to collaborate to improve services, care management and data processes.
• Ability to protect and maintain strict confidentiality regarding patient information.
• Demonstrated ability to work and communicate with people from various ethnic, socio-economic, educational and experiential backgrounds.
• Bilingual English/Spanish preferred.

Other Certifications and Experience

• Requirements:
  • Undergraduate degree or equivalent
  • Two years of hospital/clinic/medical office experience
  • Experience working with patients in the capacity of health promotion, with knowledge of medical terminology, chronic health conditions and health coaching.