Population Health Specialist

Key Responsibilities:

• Collaborate with care teams to identify, track, and close clinical care gaps (e.g., immunizations, screenings, chronic disease management) by utilizing health IT systems and registries.
• Monitor patient progress toward closing care gaps and ensure timely follow-up for all open gaps.
• Develop and implement creative strategies to ensure patients attend medical appointments and adhere to prescribed care plans.
• Measure and report on care gap closure efforts, including percentage of patients with closed care gaps, using HRSA standards and Medicaid guidelines.
• Identify and address social determinants that impact patients' ability to access care, including transportation, housing, food insecurity, and mental health.
• Refer patients to appropriate community resources and support services.
• Develop partnerships with local organizations to expand the resources available to patients.
• Create and implement innovative strategies to increase patient attendance at scheduled medical appointments, including reminder systems, transportation solutions, and extended hours.
• Coordinate with medical assistants (MAs) and LPNs to ensure patient engagement through appointment reminders, follow-up calls, and assistance with scheduling.
• Ensure timely referrals to appropriate specialists, behavioral health providers, and community services.
• Track and follow up on referral completion and report on referral effectiveness and patient outcomes.
• Work closely with interdisciplinary care teams (physicians, nurses, medical assistants, LPNs, case managers) to coordinate care and ensure that patients are receiving the right services at the right time.
• Provide case management for high-risk patients, including those with chronic conditions and frequent ER visits.
• Actively participate in continuous quality improvement initiatives and provide input on care process improvement.
• Use data to evaluate program effectiveness and make recommendations for improvement in care delivery.
• Provide training to clinical staff, including LPNs and MAs, on best practices for patient engagement, care coordination, and addressing SDOH.
• Educate patients on the importance of preventive care, self-management, and adherence to care plans.
• Ensure all care coordination activities and referrals are documented accurately in the electronic health record (EHR).
• Prepare regular reports on population health initiatives, including data on care gap closure, patient outcomes, and quality metrics.
• Ensure compliance with HRSA, PCMH, and Medicaid documentation standards.