Population Health Coordinator
Partners Community Physicians Organization(PCPO)

Somerville, Massachusetts

Posted in Health and Safety

This job has expired.

Job Info

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

  • Collaborate with care teams to establish population-appropriate, pre-visit, and point of care processes
  • Provide data to the care teams to properly perform these processes
  • Monitor and correct patient attribution to the practice and the care teams within the practice

  • Bachelor's degree preferred
  • Minimum of 2 years' experience in customer service or in a health care setting. Experience in promoting healthcare behavior change is desirable
  • Proficient in data management and reporting
  • Proven problem-solver with ability to multi-task
  • Prior use of electronic health records and other health care information systems desirable
Skills & Abilities
  • Ability to identify problems, think creatively, and devise innovative solutions
  • Strong interpersonal skills
  • Highly organized, proactive, and attentive to details
  • Ability to work as member of a collaborative team
  • Ability to persuade, influence and enlist others' support in accomplishing objectives
  • Ability to work with large data sets with guidance from medically trained individuals
  • Excellent writing and oral presentation skills
  • Spanish and other language fluency desirable
  • Working knowledge of computer software, including MS Access, Excel, Teams, PowerPoint and Word

EEO Statement
Mass General Brigham is an Equal Opportunity Employer & by embracing diverse skills, perspectives and ideas, we choose to lead. All qualified applicants will receive consideration for employment without regard to race, color, religious creed, national origin, sex, age, gender identity, disability, sexual orientation, military service, genetic information, and/or other status protected under law.

This job has expired.

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