Population Health Specialist - Boston Medical Center

Under the supervision of the Population Health Manager, the Population Health Specialist (PHS) for GIM Primary Care is responsible for providing outreach to patients in GIM Primary Care to achieve optimal population health management for preventive care and chronic disease management. The role's initial focus will be on a grant-funded, diabetes-specific health equity intervention effort, and will then transition to additional/other populations and conditions affecting GIM primary care patients. The Population Health Specialist will be responsible for conducting phone surveys, providing appointment reminders, providing patients with information on community resources, community key information to providers, and documenting updates 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.
Position: Population Health Specialist

Department: Health Equity Accelerator Fund

Schedule: Full Time

ESSENTIAL RESPONSIBILITIES / DUTIES:

1) Outreach efforts

• Provides outreach to patients via reminder calls and/or letters to ensure preventive care and chronic disease management appointments are attended.
• Documents patient interactions via registry and Epic EMR, following up with the patient, clinical pharmacist, pharmacy, and primary care provider as necessary.
• Assists with scheduling outpatient visits and follow-up appointments, as needed.
• Uses linguistically appropriate communication, coordinating with Interpreter Services, as needed.
• Surveys patients to ascertain behavioral health and social determinants needs, and facilitates patient connection, as needed, to healthcare support services, including behavioral health / social work, GIM resource navigator, specialty department navigators, and BMC financial assistance.
• Assists patient by providing information on external programs that can assist with alleviating barriers to care, including but not limited to: housing, food, medications, transportation, and other appropriate community resources.

2) Compliance and Contract reporting:

• Documents patient encounters, resource needs identification 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 the required time frames.

3) Tracking and Reporting:

• Utilizes a dashboard for tracking the effectiveness of quality programs.
• Epic EMR experience preferred.
• Microsoft Excel experience preferred.
• May work with data sets and associated analyses to monitor program effectiveness and adjust processes as necessary.

4) 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 the 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.

5) Other Duties:

• Provides other administrative and special project assistance as assigned by Population Health 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 for all confidential or sensitive information.
• Attends hospital-required and relevant training sessions or activities, as assigned by Population Health 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 Population Health Manager
• Assists in the orientation/training of new staff members.
• 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

EXPERIENCE:

• 2-3 years of experience required; preferably related to call center and scheduling work in a healthcare environment; project management, social work or program development experience is a plus.

KNOWLEDGE AND SKILLS:

• Empathic understanding of ill patients.
• Expertise in establishing working relationships with patients, their families, professionals, and the community, including the ability to collaborate with a multidisciplinary healthcare team.
• MUST be highly fluent in Haitian Creole
• Computer competency, inclusive of the ability to access and enter data.
• 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.
• Demonstrated flexibility with clients' priorities, evolving needs, and goals.
• Sensitivity to ethnic, cultural, gender, and sexual orientation diversity; values; beliefs; and behaviors.

Req id: 31428