Population Health Coordinator

Description

Salud Para La Gente (Salud) provides high quality, comprehensive and cost-effective healthcare to underserved low-income communities in the Monterey Bay area, including Santa Cruz County and North Monterey County. We began in Watsonville 1978 as a storefront “free clinic,” and with the ever-growing need for health services, in 1992 became a federally qualified community health center (FQHC). Today we are a primary health care network with 11 clinic sites, over 400 employees and continue to provide high quality services to patients of all ages.

The Population Health Coordinator will work under the supervision of the Population Health Manager to help support the work needed to maintain the agency’s status as a Patient Centered Medical Home. Specifically, the Population Health Coordinator will provide required maintenance of panels to maximize quality, safety, efficiency, patient experience and the work life of staff. The Population Health Coordinator must be detail-oriented and able to work effectively with patients, providers and support staff to provide excellent customer service. 

This position supports the organization's mission, vision, and values through excellence and competence, collaboration, innovation, respect, commitment to our community, and accountability and ownership.  

DUTIES & RESPONSIBILITIES:

1. Works with the Population Health Manager, in conjunction with clinical leadership, to ensure that each patient is assigned a primary care provider (PCP).
2. Maintains/adjusts panel sizes for each PCP based on full time equivalent (FTE), type of clinician, patient acuity, and degree of training.
3. Manages tasks sent to Empanelment Task Group.
4. Resolves unassigned patients by reviewing appointment history to determine appropriate assigned based on PCP availability using 4 cut methodology.
5. Works with Provider Schedules team to obtain quarterly empanelment FTE data for providers who carry panels.
6. Coordinates with Compliance team and PCPs monthly regarding which providers are open vs closed panel.
7. Coordinates with other support staff teams as needed regarding open vs closed panel providers.
8. Coordinates with Clinical Directors and support staff regarding panel transitions if PCPs leave Salud or reduce their primary care FTE, necessitating their patients to be transferred to a new PCP.
9. Documents/maps the workflow for PCP changes, including within the EHR.
10. Works with Compliance Team as needed to monitor number of PCP change requests by provider. 
11. Notifies patient and/or original and new PCPs once change is made, if needed.
12. Follows the necessary procedures to fix mismatches between insurer PCP assignment and clinic PCP assignment (e.g., call insurer, fill out the necessary paperwork/online forms, etc.)
13. Assists Population Health Manager to maintain master patient list for Central California Alliance for Health and Dignity patients.
14. Assists Population Health Manager to set up monthly text message campaigns to reach out to newly assigned patients inviting them to establish care at Salud.
15. Assists Population Health Manager to set up patient satisfaction surveys on a regular basis and to compile data.
16. Assists Population Health Manager to update continuity and Third Next Available Appointment measures on a quarterly and monthly basis, respectively. 
17. Works with Population Health Manager to develop and administer audit reports to support data integrity.
18. With Operations and Clinical Directors, maintains list of PCPs/Care Teams.
19. Conducts trainings including Empanelment 101 training for all staff (importance of empanelment, access & continuity); Contact Center and Front Office/Back Office training on scheduling with assigned PCP; PCP change request training for support staff.
20. Provides administrative support during PCMH and Empanelment meetings including setting up virtual and in-person meetings, taking notes and sending follow up emails.
21. Consistently adheres to and/or exceeds SPLG’s communication guidelines and expectations with internal and external customers including co-workers, patients, and external partners.
22. Communicates effectively by using welcoming words, proper tone of voice, appropriate body language, eye contact and smiling in all interactions. Listens skillfully and displays a willingness and ability to acknowledge patient and co-workers’ needs, expectations and values through the use of reflective listening and empathy conveyance. Responds to co-worker and patient needs in ways that are helpful and beyond expectation.
23. 14. Other duties and projects as assigned.
24. a. Updates on a regular basis provider panel lists to adjust panels according to PCP’s empanelment FTE.
25. b. Works with the Population Health Manager to assist with any needed clean-up efforts around Care Team assignment (which serves as empanelment designation for specialty team members such as Behavioral Health/Psychiatry, Neurology, etc.)
26. 15. Works with clinical leadership and the Population Health Manager to maintain policies and procedures around empanelment:
27. a. Indicating how new patients will be assigned, considering Medi-Cal and other health plan PCP assignments.
28. b. Dictating if, when, and how panels will be closed.
29. c. Specifying any balancing of patient types among panels (i.e. task/work-based; demographic-based; condition-based, etc.)
30. Knowledge of: health care delivery systems administrative practices; information technology systems 
31.  applications, database management, database reporting, and electronic health/dental record systems.
32. Ability to: assume independent responsibility for assigned projects and tasks; strong interpersonal skills including the ability to work well with people with different backgrounds; ability to work on several projects simultaneously; strong analytical skills with the ability to focus on detail; ability to identify potential issues and participate in their resolution; communicate well both in writing and verbally; perform job duties accurately, effectively, and in a timely manner; and present information in internal meetings

Requirements

MINIMUM REQUIREMENTS

• Bachelor’s degree required. Three (3) years of relevant process improvement and project coordination experience may be considered in lieu of degree in addition to the experience below. 
• At least 3 years’ experience working in a healthcare setting.
• Strong data and analytical skills.
• Proficient in Microsoft Office, Word, Excel, PowerPoint, Outlook or related software

PREFERRED QUALIFICATIONS

• Organized and detail-oriented; strong problem-solving skills; ability to work independently.
• • Excellent communication skills, verbally and written, with ability to generate professional, clearly written communication that is tailored to the audience.
• • Excellent facilitation, conflict resolution, and interpersonal skills.
• • Knowledge of population health programs and resources preferred.
• • Knowledge of electronic health/dental record systems preferred.
• PHYSICAL DEMANDS
• • Standing, walking, sitting, typing, reaching, moving and/or lifting up to 25 pounds.