Population Health Specialist

Job Summary Works under the direction of the Director of ACO Operations in the area of Transitional Care Management. A prime area of focus will be supporting transitional care activities of patients discharging from acute and post-acute facilities. Other areas of focus may include chronic care management, population health management, quality improvement, and provider and staff education. Performs selected clinical and administrative duties that support patient care and clinical operations. Minimum Qualifications Education: High school diploma or equivalent. Successful completion of accredited Medical Assistant program or equivalent medical training. Preferred Experience/Qualifications: Five years of experience as a Medical Assistant in a primary care setting. . Other Qualifications: Preferred - knowledge of clinical quality metrics, motivational interviewing and patient education techniques. Proficient use of Microsoft Excel. Responsibilities Provide care coordination interventions to a panel of medium and low risk patients to improve clinical outcomes and help reduce re-admissions to acute care settings. Assist in ACO-directed quality improvement efforts. Interact with internal and external care team members to provide care coordination for patients needing short-term care coordination and safety interventions after discharge from acute care facilities, post-acute care facilities, or emergency departments. Communicate significant clinical information regarding these patients to other members of the healthcare team and especially to the patient’s PCP. Attend case conferences in regards to patient collaboration Provide nursing services and patient education in accordance with Arizona Board of Nursing Act as a liaison between community resources helpful to patients (e.g. volunteer agencies, assistance programs) and ACP staff and providers. Use advocacy, communication and resource management, while promoting quality and cost-effective interventions and outcomes. Facilitate the achievement of patient wellness and autonomy through communication, education, resource management, and service facilitation. Maintain appropriate documentation to track quality improvement and cost reduction activity. Customer Service: Promotes excellence in patient relations and customer service, emphasizing compassion, responsiveness, respect and courtesy. Uses active listening skills, gathering information to enhance patient care. Teamwork: Works harmoniously with others, demonstrating a commitment to achieving common goals. Communicates in a manner that promotes trust and mutual respect. Maintains a professional demeanor in dealing with conflict and difficult issues. Adapts to changes in job duties and workplace with a positive and cooperative demeanor. Attendance: Accurately records arrival/departure times and hours worked and adheres to the established attendance policy. Contacts supervisor appropriately with any schedule deviation. Appearance: Maintains personal grooming and hygiene consistent with ACP policy. Physical Requirements and Working Conditions During an 8-hour day will typically spend six hours sitting in continuous periods of 60 minutes or more, viewing a PC monitor and utilizing a computer keyboard. Uses telephone for prolonged periods while performing clerical duties. Frequent walking and standing. Occasional lifting, bending, stooping, walking or standing with up to 20 pounds (boxes of paper or records, office equipment). The intent of this job description is to provide a summary of the major duties and responsibilities performed by individuals in the job title. Individuals may be required to perform additional job-related tasks as needed.

Education requirements

Minimum Qualifications Education: High school diploma or equivalent. Successful completion of accredited Medical Assistant program or equivalent medical training.