Population Health Support Staff - Lone Star Circle of Care

Overview

The Population Health team at LSCC manages organizational performance on clinical metrics, patient engagement, and cost containment for value-based contracts. Clinical Support staff on this team work in a central hub, remotely assisting clinic-based team members in managing panels of patients and closing any gaps in metric performance.

Support staff on this team primarily perform telephone-based outreach to patients, but also assist with medical record abstraction and appointment scheduling. Indirect patient care is provided via telephonic and/or other electronic communications, and effectively engaging patients is an important part of this role. A friendly phone voice and empathetic personality are critical! Staff perform duties under the direction of the Chief Medical Information Officer as well as nurses (RNs and LVNs) on the Population Health Team to assist in the provision of patient care and healthcare system navigation.  

Responsibilities

Daily Job Duties:

• Perform outreach to patients as directed using telephonic and/or other communication modes (text, email, portal, mail). Use navigation center web-based call platform when placing outbound calls. Daily duties entail a high volume of outbound calls where performance is measured (i.e., number of calls placed, percentage of calls that result in a positive outcome, such as scheduling an appointment).
• Perform and ensure proper documentation of patient communications and clinical treatment accurately in the use of the Electronic Health Record (EHR) system
• Using scripting developed by RNs, and under their direction, educate patients about wellness, routine preventive care, and screenings. Encourage follow through with recommended tests and treatments. Encourage patient engagement with the Population Health team.
• Obtain, evaluate, and record information in patient record
• Perform patient screenings (e.g., socioeconomic barriers to care, depression screening, tobacco use screening) electronically, and based on screening results, assist patients in obtaining any necessary social services or medical care
• Interact with LSCC healthcare providers to provide optimal care for our patients through electronic communication (bidirectional tasking in the EHR; recording your outreach work in the EHR’s care coordination template)
• Communicate with external healthcare organizations to obtain the status of patient appointments or referrals
• Engage patients with the Population Health team by serving as their advocate in willingly assisting in healthcare system navigation, in inquiring about barriers (cost, transportation), and informing patients about social services available to them.
• As experience and licensure permit and under the direct supervision of team RNs, assist with clinical tasks (performed centrally, at the navigation center, not in clinics) as assigned. May include, but not limited to, responding to task requests from providers, completing prior authorizations, processing referrals, and filing of triage reports and medical records.
• Utilize the Population Health team’s electronic ticketing system to track daily and weekly task assignments and mark completed tasks as done
• Perform administrative tasks such as faxing, scanning of documents into the EHR, and activities related to bulk communications (printing of letters and stuffing envelopes for bulk mailings; sending individual scripted emails or text messages as part of outreach campaigns)
• Participate in all trainings and refreshers as appropriate.
• Participate and collaborate in team meetings.
• All other duties as assigned

Compliance/Customer Service/Training:

• Maintain patient care standards following established LSCC health education and information guidelines
• Participate in quality improvement initiatives
• Organize work and utilize time efficiently based on knowledge and procedures
• Assume responsibility for his/her own professional development and for sharing knowledge with others
• Invest own time and effort to improve knowledge, skills and judgment
• Responsible for knowledge and compliance of all LSCC policies and procedures
• Maintain professional manner and appearance

Qualifications

REQUIRED EXPERIENCE, EDUCATION, AND LICENSE:

• High School Diploma or GED
• Minimum of three (3) years of work in the healthcare field involving direct interaction with an electronic health record and/or practice management application

PREFERRED EXPERIENCE, EDUCATION, AND LICENSE:

• Medical Assistant (MA) certification or experience preferred but not required; salary commensurate with certification and experience
• Bilingual English/Spanish language skills is required.
• Proficiency with MS Office Suite (Word, Excel, and Outlook)