Population Health Specialist - Boston Medical Center

POSITION SUMMARY:

Under the supervision of the Administrative Manager, the Population Health Specialist for GIM Primary Care is responsible for providing outreach and supporting patients in GIM Primary Care to receive optimal population health management for preventive care and chronic disease management.

The Population Health Specialist will assist in case management services for GIM Primary Care patients, developing a service plan based on identified needs, facilitating access to social service benefits and other internal and external resources, monitoring the patient's progress, and tracking practice performance. Responsible for documentation in the electronic medical record and complying with all data entry, data integrity, and data tracking requirements for BMC and funding agencies' contract monitoring reports as required. The Population Health Specialist will also assist with various projects to improve the quality, effectiveness, and efficiency of services provided in clinic to improve population health.

Position: Population Health Specialist

Department: Primary Care Clinic

Schedule: Full Time

ESSENTIAL RESPONSIBILITIES / DUTIES:

1) Assessment:

• Provides advocacy and case management services for patients (medical and social case management) under the supervision and direction of the Population Health Manager.
• Assesses patient and family to ascertain those emotional and social problems, and identifies barriers to care, and formulates plan
• Assists patients by linking them to a broad range of services, including, but not limited to, healthcare support services, social work, GIM resource navigator, specialty department navigators, financial assistance, child-care, housing, food, clothing, transportation, food pantries, and appropriate community resources.

2) Outreach efforts

• Monitors patients' progress via registry and EMR, following up with patient and primary care provider as necessary.
• Provides outreach to patients via reminder calls and/or letters to ensure preventive care appointments are attended

3) Appointment/Visit Support

• Prepares population health forms for patients prior to appointment date
• Supports primary care provider during patient visit, accepting warm hand-offs for education or appointment scheduling as needed.
• Assists with scheduling outpatient visits and follow-up appointments as needed
• Provides education and supports patients. Uses a variety of culturally, linguistically and educationally appropriate strategies, in a variety of settings. Coordinates with Interpreter Services, as needed.
• Develops and maintains strong relationships with the community and resources to ensure patient access.

4) Compliance and Contract reporting:

• Documents patient encounters, resource development efforts, and other interventions for each patient, including date, time, and signature in the electronic medical record.
• Complies with departmental, regulatory and contract requirements for documentation recording, and data collection, and submits department statistics and other records and reports within required time frames.

5) Tracking and Reporting:

• Utilize dashboard for tracking effectiveness of piloted programs
• Requires Microsoft Excel skills
• Will work with large data sets and associated analyses to monitor program effectiveness and adjust processes as necessary

6) Quality and Performance Improvement Projects:

• Identify opportunities to promote population health by improving GIM's provision of services
• Analyze data on access, service delivery, and patient experience
• Interview providers, patients, and other hospital subject matter experts
• Research and implement alternative methods and processses

7) Meets hospital-wide standards in the following areas:

• Conforms to hospital standards of performance and conduct, including those pertaining to patient rights and privacy
• Utilizes hospital's policies and standards as the basis for decision making and to support the hospital's mission and goals.
• Follows established hospital infection control and safety procedures

8) Other Duties:

• Participates in Grant writing, grant reporting, and in the preparation of program summaries
• Assists in the preparation of abstract writing and presentations for national conferences
• Coordinates and provides trainings for patient navigators and care coordinators at community health centers
• Provides other administrative and special project assistance as required or assigned by Practice Manager
• Remains knowledgeable of and follows appropriate policies, procedures, and work standards, including but not limited to, policy regarding hours of work, absenteeism, and tardiness.
• Maintains competency in areas of responsibility to ensure quality of care.
• Maintains strict protocols of all confidential or sensitive information
• Attends hospital required and relevant training sessions or activities, as assigned by Practice Manager.
• Promotes a positive and collaborative work environment supportive of the hospital's missions and goals.
• Provides a link between the GIM Primary Care and other hospital departments.
• Adapts to changing departmental needs, including but not limited to, offering assistance to other team members, adjusting assignments, and other functions as determined by Practice Manager.
• Assists in orientation/training of new staff members and volunteers.
• Performs other duties assigned or as necessary.

Must adhere to all of BMC's RESPECT behavioral standards.

(The above statements in this job description are intended to depict the general nature and level of work assigned to the employee(s) in this job. The above is not intended to represent an exhaustive list of accountable duties and responsibilities required).

JOB REQUIREMENTS

EDUCATION:

• Bachelor's degree required

CERTIFICATES, LICENSES, REGISTRATIONS REQUIRED:

• None

EXPERIENCE:

• 3-5 years of experience required; preferably related to project management, social work or program development.

KNOWLEDGE AND SKILLS:

• Knowledge of community, social, and health resources
• Empathic understanding of ill patients and skilled in performing multicultural needs assessments and developing concrete service plans.
• Expertise in establishing working relationships with patients, their family, professionals, and the community, including the ability to collaborate with a multidisciplinary health care team.
• Computer competency, inclusive of the ability to access and enter data.
• Ability to understand and interpret complex data analyses
• Ability to work in a fast paced environment, inclusive of organizational skills, critical thinking, and problem solving abilities.
• Effective verbal, written, and interpersonal communication skills to facilitate interactions with various members of the health care team, patients, and their families.
• Bilingual or multi-lingual skills (beyond that of English) appropriate to the patient population served, is preferred.
• Demonstrated flexibility with client's priorities, evolving needs, and goals.
• Sensitivity to ethnic, cultural, gender, and sexual orientation diversity; values; beliefs; and behaviors.
• Demonstrated critical thinking and problem solving ability.

Req id: 30299