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Population Health Specialist

Job ID 148900 Date posted 09/11/2018

Position Summary:
Lahey MassHealth ACO (LMH-ACO) is responsible for improving coordination of patient care, reducing unnecessary hospitalizations and readmissions, emergency department visits and revisits, and reducing total cost of care over time. LMH-ACO will provide services in collaboration with contracted Managed Care Organizations as well as Community Partners for Behavioral Health and Long Term Services and Supports, as appropriate.

Under the supervision of the Director of Quality, the Population Health Specialist supports collaboration, communication and care coordination with all members of the health care team. The Population Health Specialist is an integral member of the health care team who works to ensure safety, best practice and high quality standards of care across the health care continuum to achieve the quality incentives as part of global payment and managed care contracts with the goal of optimizing our patients' health and well- being. Their role is to assist the health care team by coordinating registry based quality measures of care for both scheduled and nonscheduled patients by proactively managing and coordinating quality measures to offer complete preventive and chronic care management for all patients identified by the Lahey Clinical Performance Network (LCPN). The Population Health Specialist coordinates health services and provides support, encouragement and education to achieve the highest level of self-management within their responsibilities for each identified patient population.

Essential Duties & Responsibilities including but not limited to:
1. Coordinates care for identified patients across the continuum in collaboration with physicians and all members of the health care team for populations identified by LCPN and supervised by the Director of Quality.
2. Serves as the liaison with patients, families to physicians, clinical staff, inclusive of Ambulatory Care Management, Inpatient Case Managers, and other departments within Lahey, 3rd party insurers involved with patient care, and community and post-acute care providers.
3. Advocates for patient and families, responds to and facilitates resolution of patient questions and concerns within scope of responsibilities.
4. Reviews, manages and enters registry health data for identified patient populations.
5. Extracts data from Optum and practice electronic medical record to support LCPN reporting and monitoring of quality performance.
6. Monitors compliance by the utilization of registries to proactively reach out to patients to assure they are making appointments, keeping scheduled appointments and complying with preventative care goals.
7. Reviews provider schedules and individual patient charts and assist the care team in coordinating care for visits and for future healthcare needs
8. Supports process improvement to enhance physician and staff workflow
9. Handles new patient outreach and non-compliant patient activation
10. Provides an effective communication link between patient and medical staff, including relaying messages from providers, gathering information from patients for providers etc.
11. Participates in team decisions regarding data requirements for pro-actively managing the team?s panel
12. Reviews registries with PCPs and/or key office staff to determine the next phase in patient care. Facilitates appointment scheduling, telephone outreach and directs patient to educational resources.
13. Coordinates with Director of Quality to track and share data with practice on patient experience improvement measures and performance against goals.
14. Performs other duties as assigned


Minimum Qualifications

Education: Medical Assistant Certification or at least 2 years (90 credits) of college preferred or minimum 5 years related experience in an health care environment

Licensure, Certification & Registration: Health Coach Certification preferred

Experience: Prior experience working as a Medical Assistant preferred or other health related field. Strong knowledge in Microsoft Office applications ? Word, Excel, Access, PowerPoint. Knowledge of the electronic medical record eClinical Works a plus.

Skills, Knowledge & Abilities:
- Strong interpersonal and customer service skills required to communicate with patients, family members, physicians and other health care providers, as well as other colleagues.
- Knowledge of medical terminology.
- Must possess strong problem solving abilities and analytical skills to ensure patient?s needs are met.
- Demonstrates, after receipt of training, ability to use all applicable electronic systems/applications including but not limited to the Patient Registry, Electronic Health Record (EHR) and population management systems to input, retrieve, and manipulate clinical information, as well as patient registration and appointment information. Must be highly attentive to detail, accuracy, and achieving end results.
- Utilizes critical thinking and good judgement in performance of tasks.
- Must possess good organizational skills and the ability to multitask and to prioritize daily assignments to ensure smooth work flow
- Advanced skills with Microsoft applications which may include Word, Excel, PowerPoint or Access and other web-based applications. May produce complex documents, perform analysis and maintain databases.
- Understands and complies with highest standards of confidentiality.



About Lahey Health

The Lahey Model of Care - right care, right time, right place - is exactly what patients, providers and payers need and deserve. Identifying and delivering on this convergence of interests has positioned Lahey Health for further growth. Our model ensures care is highly coordinated and locally delivered, with lower costs and exceptional quality.

Lahey Health is a robust, regional system including a teaching hospital, community hospitals, primary care providers, specialists, behavioral and home health services, skilled nursing and rehabilitation facilities, and senior care resources throughout northeastern Massachusetts and southern New Hampshire. The system has a global presence with programs in Canada, Jordan and Bermuda.

How To Apply

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