Pop Health Specialist

The Population Health Specialist collaborates closely with the Care Management team, healthcare professionals, and providers within the RDC network to coordinate care across the healthcare continuum. This role focuses on improving outcomes for attributed populations by supporting care transitions, identifying at-risk patients, and addressing gaps in care. Key responsibilities include care coordination, patient outreach, and assisting providers in managing population health strategies to ensure continuity, quality, and efficiency of care delivery.

Education:  2 Year associate’s degree, preferred

License/Certifications:  Certificate in Medical Assisting (Preferred)

Language Skills:  Bilingual (desired)

Other Skills:  Minimum one year of recent experience working in a medical facility. Excellent human relation skills, possess effective oral and written communication skills, leadership and problem solving skills, operate personal computer. Ability to successfully complete required training.

Expected Hours of Work:  Monday – Friday

Supervisory Responsibility:  None

ESSENTIAL FUNCTIONS:

1. Assist in closing the health care gaps by working with insurance programs on identified attributable lives by documenting and collecting pertinent medical information from the patient and their records.
2. Ensures all patient encounters are effectively and accurately documented within EHR.
3. Use of spreadsheets to identify patients overdue for chronic disease care and preventive care
4. Orders overdue or upcoming care, using motivational interviewing to discuss services due with patients based on standing orders and patient specific medication adherence.
5. Calls patients who are overdue on preventive screenings and uses motivational interviewing techniques to encourage patients to come in.
6. Assist in advance pre-visit planning (1 to 2 weeks ahead of patient's scheduled visit).
7. Follows up on previous orders and consults with primary care providers.
8. Documents data from new patient records and specialist reports.
9. Updates previous medical, social, and surgical history from consults, emergency department, and hospital reports.
10. Enters data in discrete and appropriate fields.
11. Ensures follow-up if appropriate to close care gaps.
12. Documents patient responses to standardized screening questions for various care management programs.
13. Transition of care backup.
14. Ability to sit at length making patient telephone calls.
15. Direct face-to-face patient interaction to obtain information.
16. Diabetic eye exam support which requires training
17. Other duties as assigned.