General Summary / Overview Statement
The Population Health Coordinator supports the development of patient-centered, team-based care. S/he will remotely support primary care physicians (PCPs) and practices in managing their panel of patients using a registry population management informatics tool. By gathering and organizing patient data, the Population Health Coordinator works to identify patients' unmet needs, engage patients in their own care, gather summary information for treatment interventions, and enhance ongoing communication between the patient and her/his care team. The goal of the Population Health Management (PHM) program is to facilitate high-value, patient-centered care that improves timely access to and provision of preventive services and chronic disease treatment.
This is a hybrid role with the opportunity for remote work, as well as on-site. The on-site expectation is one day per week at our Assembly Row Headquarters in Somerville.
Key Areas of Responsibility
• Develops a keen understanding of primary care practice requirements for optimal, coordinated population health
• Works as an effective team member of the population health management program
• Manages data collection using a registry, prepares reports on findings, and provides interpretations and recommendations to each practice
• Contributes to quality improvement and care redesign of population health efforts
Principal Duties and Responsibilities:
• Manage patient registries and provide the members of health care teams in designated practices with the data required to meet the health needs of the practice
• Support practice staff to develop creative processes to proactively manage target populations
• Provide data management, coordination, and patient outreach as needed for
specific target patient populations
• Contributes to a positive experience for patients and families through courteous telephone interactions and interview activities, accurate and expeditious routing, as well as referral to appropriate clinical staff when necessary
• Respond to inquiries from the practice regarding outcomes of outreach calls to patients
• Synthesize, sort, format data, and generate ad-hoc reports. Present data to each of their assigned primary care practices
• Assist in process mapping and development of workflows for population health management at each of the designated primary practices.
• Answer and/or research questions on problems the clinicians have identified
• Recognize and report data inconsistencies to appropriate personnel
• Contributes to the teamwork within and between departments. Regularly attends and participates in meetings with coworkers and practice staff. Provides constructive ideas, suggestions, and feedback in a positive manner. Works collaboratively with co-workers to effectively resolve issues that impact departmental or hospital operations
• Perform all job functions in compliance with applicable federal, state, local and company policies and procedures
• And other duties as assigned
Quality Improvement and Process Design