Description

POSITION SUMMARY

Manage an assigned patient caseload and collaborate with patients, providers, and practice teams to assess patients’ needs and ensure overall wellbeing. Develops, implements, and evaluates population health, quality, and practice transformation strategies while coordinating a variety of outreach and enrollment programs designed to identify under-served population segments and aid with accessing services while providing the best possible care to the communities we serve. 

Requirements

ESSENTIAL DUTIES AND RESPONSIBILITIES (Included but not limited to the following:)

• Participates (as directed) in the screening of new service requests within the clinic by means of an agency-approved procedure that ensures that all individuals are adequately and appropriately served according to their individual needs and in accordance with existing Board policies and procedures. 
• Completes, reviews, and assesses patient data, to assist in validating HEDIS guidelines have been met while promoting patient awareness of the importance and the availability of screening and living healthy lifestyles to improve HEDIS measures 
• Provides on-going support in accordance with the problems, needs, and the strategies identified within the service plan to help patients achieve stated goals and objectives. 
•  Provides face to face reviews with the patient and/or relevant staff on a regular basis to assess the progress made in reaching service goals so the service plan can be modified (as necessary) to ensure goals and objectives are being achieved. 
• Participates in interagency planning and service coordination activities directed to improve and enhance service continuity and effectiveness for patients to include provider referrals to interagency programs and conduct follow up calls for “member no shows” from referrals.
• Coordinates outreach events to FHCN partners and other entities focused on Fetter Health Care Network’s target patient population to include migrant and seasonal agricultural workers (MSAW) and those experiencing homelessness
• Partners with School-Based Clinics to optimize quality care provided to students within the schools to include coordinating appropriate follow up care as needed. 
• Monitors, track, and close gaps in patient health care reports to optimize care.
• Assists with community events, collaborate with internal teams, assist patients with scheduling appointments with their providers, and promote patient and public awareness of the importance and the availability of screenings and services in support of healthy lifestyles 
• Partner with various organizations to verify accurate patient data reporting. 
• Acknowledges and follows all HIPAA guidelines and regulations regarding patient confidentiality while documenting (on a timely basis) and maintaining information
• Securely accesses, documents, transmits, and maintains patient medical records via electronic software. 
• Provides guidance and counsel regarding Social Service needs (Insurance Eligibility, ACA, SC Thrive, Access Health, Food Bank, Prescription Assistance, etc. 
• Applies population health and Triple Aim concepts and implements appropriate quality improvement methodologies (such as Model for Improvement, Lean, PDSA’s, or other appropriate methodologies) to assure highest standards of population health and quality improvement infrastructure and performance. 
• Collaborates with key FHCN partners on population health, quality improvement and health system innovation strategies and initiatives. 
• Other duties as assigned

 REQUIREMENTS

• Bachelor's degree (or higher) in Public Health, Healthcare Administration, or Human Services preferred
• Minimum of two years experience working in population health, quality improvement or related field preferred 
• Ability to travel extensively within assigned communities.