Population Health Advocate

Description

Essential Duties and Responsibilities :

• Reviews patient registries and other data sets to identify gaps in care, disease specific screenings, and basic preventative health screens. Communicates with patient and / or clinic staff, to ensure timely closure of identified gaps.
• Documents activities / interventions within patient charts or other reporting formats, as appropriate.
• Collects and tracks monthly, quarterly, and annual process improvement / quality measure data.
• Conducts analysis of data in collaboration with a variety of care teams to assist in identification of improvement activities. Presents data collected in an organized format to facilitate analysis and identification of improvement opportunities.
• Accesses daily reports to identify patients hospitalized, discharged, and treated in the Emergency Department (ED). Provides assistance with care coordination, facilitates communication between patients, caregivers, and providers, helps to addresses barriers to care, and promotes optimal allocation of resources.
• Provides information to patients and families regarding community resources, medication assistance, and other healthcare needs.
• Implement / assist with a variety of healthcare quality improvement / population health activities, as indicated and directed.
• Participate in the development, implementation and / or evaluation of FCCH PCMH initiatives.
• Conduct patient chart reviews for pre-visit planning using standard protocols to enhance visit efficiency and effectiveness.
• Assists patients with scheduling, ordering lab work, and / or testing that may be needed for a chronic disease as defined in the organizational standard protocols.
• Participate in patient outreach (via phone, virtual platform, clinic, and / or home visit) to achieve greater patient compliance with appropriate treatment plans, standards of care / protocols and improved patient healthcare outcomes.
• Supports patients in an effort to make them successful while following the written plan of care, as indicated in the discharge plans and ambulatory care plan. Encourages patients to use self-management tools as provided.
• Facilitate patients’ access to available community support, educational and / or other healthcare resources, as appropriate to their needs and according to any requirements of health insurance or healthcare financial assistance programs they may (or may not) have.
• Other duties, as assigned and / or needed.

Requirements

Minimum Qualifications & Experience :

Age of Patients Served :

Physical Characteristics / Working Conditions :

A person in this position has sufficient time to complete most tasks, although under pressure depending on patient and organization needs. There are frequent opportunities to relax from any physical exertion or to change position in work activities.