Population Health Coordinator
Newton-Wellesley Hospital(NWH)

Newton, Massachusetts

Posted in Health and Safety

Job Info

This innovative program is comprised of a team of centrally based Population Health Coordinators (PHCs) who are assigned to support designated Primary Care practices and are expected to function as integral members of both their central team and practice-based teams.

Using population registries and related data, PHCs work with their assigned practice teams to ensure that patients receive recommended condition-specific services. For example, PHCs will: coordinate proactive patient outreach to schedule follow up appointments, screen/monitor patients using questionnaires regarding mental health or other conditions, coach patients as they prepare for cancer screening procedures, and provide reminders about their pre-visit lab tests.

PHCs are also expected to monitor and extract reports from patient registries and share with their designated practices population level data and outcome measures on a regular basis. S/he will 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 PHC 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 Management Program is to facilitate high-value, patient-centered care that improves timely access to and provision of preventive services and chronic disease treatment.

Key Areas of Responsibility:

  • Gathers and manages quantitative and qualitative patient data using EHR population registries and evidenced-based assessment tools
  • Learns and understands Primary Care practice workflows with respect to optimal and coordinated health care for target patient populations
  • Develops a keen understanding of primary care practice requirements
  • Manages patient data collection and generates reports that are convenient for analysis and meet both CPM/PHO and practice requirements
  • Conducts timely outreach tailored to meet each patient's condition specific needs
  • Contributes to Quality Improvement and Process Design of Population Health efforts
  • Follows established communication protocols and informs clinical team and program leadership accordingly
  • Participates in improvement projects within NWPHO Population Health programs including iCMP and Collaborative Care Teams
  • Collaborates on improvement projects across RSO specialty departments (e.g Orthopedics, Cardiovascular Medicine, Endocrinology)
Principle 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 and provide data support and population health education when applicable
  • Provide data management, coordination, and patient outreach as needed for
    specific target patient populations
  • Respond to inquiries from designated practices in a timely manner
  • 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
  • Help mentor new hires during the onboarding process and assist in cross coverage as needed
  • Contribute to the teamwork within and between departments. Regularly attend and participate in meetings with coworkers and practice staff. Provide constructive ideas, suggestions and feedback in a positive manner. Work 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
  • Attend practice and central team meetings as directed
  • Provide regular updates and reports to the Medical Director, Practice Manager and PHO Manger
  • Other duties as assigned
Quality Improvement and Process Design
  • Collaborates with care teams to establish culturally sensitive, population-based interventions and workflows to reconnect patients to care
  • Works closely with practice teams planning tests of change by participating in the planning, implementation and analysis of PDSA improvement cycles as appropriate
  • Monitors and corrects population registries under the direction of the Provider 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
  • Ability to identify problems, think creatively, and devise innovative solutions
  • Polished interpersonal skills
  • Highly organized, self-directed and able to accomplish daily workflows in remote, central office and practice-based settings
  • Ability to work as a member of a collaborative team and engage others in efforts towards accomplishing objectives
  • Ability to work with large data sets with guidance from medically trained individuals
  • Excellent writing and oral presentation skills.
  • Working knowledge of computer software, including, Outlook, Excel, PowerPoint and Word.
  • Prior use of electronic health records and other health care information systems desirable
  • Desire to work as part of an interdisciplinary team to improve patients' health and wellness

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