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Population Health Outreach Specialist

Boston Medical Center

This is a Part-time position in Lake City, FL posted August 3, 2022.

POSITION SUMMARY:The Population Health Team serves as the central hub for programs that drive performance in the Medicaid ACO program.

As part of the MassHealth effort to transform healthcare via formation of Medicaid ACOs, Boston Medical Center Health System has partnered with providers across the state to share risk in caring for Medicaid populations.

In order to succeed in this program, BMCHS designs and implements programs that improve quality of care for Medicaid populations, as well as manage utilization and total cost of care.The Population Health Outreach Specialist is a critical member of the team who coordinates and supports this work.

The Population Health Outreach Specialist works with internal and external contacts to organize and conduct outreach to patients across multiple primary care practices to meet the Quality goals of the Population Health team.

Duties include performing patient outreach, coordinating schedules and activities, supporting meeting preparation, tracking progress and results, and placing orders for supplies and services.

Requires excellent communication skills and extensive knowledge of database and project management software.Position: Population Health Outreach Specialist Department: Population HealthSchedule: Full TimeESSENTIAL RESPONSIBILITIES / DUTIES:The Population Health Outreach Specialist works with internal and external contacts to implement outreach for the Population Health team.

Duties include outreaching to patients, coordinating schedules and activities, placing orders for supplies and services, and tracking progress and results.

Requires excellent communication skills and extensive knowledge of database and project management tools.

Close collaboration is required with the other members of the Quality team.Specific activities may include, but are not limited to, the following:OutreachConducts and coordinates timely, proactive patient outreach (telephonic, written, and in clinic) to schedule follow up appointments, coach patients as they prepare for appointments and/or routine screenings, and provide pre-visit reminders as needed.

Follows up on patients who cancel or do not arrive to their appointments.Work with Quality Manager to review quality data to identify outreach needed.Schedules outpatient visits and follow-up appointments working closely with internal and external resources to ensure patient is prepared to arrive to appointmentsProvides education, counsels, and supports clients.

Uses a variety of culturally, linguistically and educationally appropriate strategies, in a variety of settings.

Coordinates with Interpreter Services, as needed.Collaborates and coordinates with health care team members, including social work and other resources, to promote positive prevention, harm reduction.Ability to track and summarize outreach efforts for reporting purposes.Refines outreach, pre-visit and post-visit workflows as neededCompliance and Contract ReportingIdentifies patients whose chronic conditions require increased surveillance to maintain good health and minimize complications.Collaborates with other departments to improve efficiency and care coordinationUtilize registry/EMR to generate reports that will inform the population health management programUtilize dashboard for tracking effectiveness of programs and/or pilotsAbstracts clinical data for MassHealth other quality initiativesConducts chart reviews to ensure proper documentation for quality reporting.Population Health Program ImplementationOutreaches to MassHealth Members to assist them in scheduling appointments for lab draws, obtaining blood pressure readings, and mailing FIT kitsEngages with the BMCHP team to liaison between risk adjustment vendors and clinical teams to triage appropriate information and ensure it gets to the primary care teams based on designated protocolsPerforms other duties as neededMust 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 REQUIREMENTSEDUCATION:Requires Bachelor’s degree (or equivalent combination of formal education and experience).CERTIFICATES, LICENSES, REGISTRATIONS REQUIRED:NoneEXPERIENCE:Minimum 3-5 years of relevant post-collegiate professional experience required.

Previous project coordination also preferred.At least 1 year of experience working in a health care setting required.KNOWLEDGE AND SKILLS:Excellent verbal/written English communication skills, including excellent grammatical, editing and proofreading skills.Advanced skills with Microsoft applications (Outlook, Word, Excel, PowerPoint, Access) and other web-based applications.Ability to produce complex documents, perform analysis and maintain databases.Ability to work independently and exercise independent judgment.Excellent interpersonal skills necessary to be socially perceptive in accepting and relaying confidential information, communicating policies and procedures, and interacting effectively with a variety of Medical Center personnel and outside personnel.Strong problem solving skills.Proven ability to work with confidential information.

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