Population Health Specialist

3 weeks ago

Lewes, Delaware, United States Beebe Healthcare Full time
Population Health Specialist

Beebe Healthcare is seeking a dedicated and compassionate Population Health Specialist to join our team. As a trusted member of the community, you will serve as a liaison between health/social services and the community to facilitate access to services and improve the quality and cultural competency of service delivery.

Responsibilities:
  • Assist patients and families in navigating and accessing healthcare, community services, and resources
  • Promote adoption of healthy behaviors
  • Build and maintain relationships with patients via telephone, clinic sites, mobile health clinics, home visits, and community locations
  • Provide appropriate training and oversight
  • Support providers and Care Coordinators with care management and community outreach
  • Promote, maintain, and improve the health of patients and families
  • Behave professionally and promote values of respect, exceptional service, continuous improvement, safety, trust, and transparency
  • Pursue excellence in improving community health status
  • Be patient-centered, flexible, and organized
  • Assess social needs using a standardized social barrier assessment tool
  • Link participants with community resources to address health-related social needs
  • Link participants to clinical and administrative services
  • Assess functional and social needs of members and collaborate to develop and implement solutions
  • Establish goals and care plans to meet functional and social needs
  • Implement care plans
  • Work collaboratively with the multidisciplinary team to address medical, functional, and social barriers to care
  • Bridge gaps for previously un-engaged patients and those with lost contact
  • Identify, refer, and coordinate available community resources for non-medical needs
  • Ensure patient access to services
  • Register and schedule patients in the EMR
  • Accurately document in patients' electronic medical records (EMR), using Athena and/or Cerner
  • Document patient interactions for follow-up purposes
  • Provide patient and family education regarding follow-up needs during visits
  • Participate in organizational quality initiatives
  • Participate in multidisciplinary team meetings to optimize care delivery
  • Commit to the mission, vision, and strategic goals of Beebe Healthcare, integrating values of compassion, integrity, and performance
Qualifications:
  • Ability to travel up to 50% of the time for field-based work
  • Required to have a dedicated work area established that is separated from other living areas and provides information privacy
  • Ability to keep all company sensitive documents secure
  • Demonstrates sensitivity and empathy in dealing with patients and families under stress
  • Uses knowledge and judgment in assisting patient and families in problem solving
  • Utilizes decision making skills in evaluating alternatives and determining best plan of action
  • Works under pressure of time and shifting priorities
  • Ability and willingness to self-motivate, prioritize, and be willing to change processes to improve effectiveness and efficiency
  • Adapts to changing patient and/or organizational priorities
  • Ability to drive to and from a variety of settings in varying weather conditions
  • Excellent organizational skills
  • Knowledgeable of local community resources
  • Previous experience as a CHW and knowledge of community resources highly desirable
  • Soft Skills: Knowledge of culture and values of communities served Familiarity with the resources available in Sussex County Ability to work with diverse care teams
  • Exhibit independent professional judgement within boundaries of role, but the ability to consult and engage with other team members for improved patient outcomes
  • Valid Delaware driver's license and access to an insured automobile that lists employees on the insurance policy
  • Familiarity with Microsoft Office applications (i.e., Word, Excel, Outlook)
  • Ability to deal with frequent changes, delays, and/or unexpected events
  • Ability to establish positive, supportive, and trusting relationships with and among patients, their family members, and colleagues
  • Ability to work collaboratively and effectively within a team
  • Ability to take the initiative, problem-solve, and make decisions
  • Having empathy and compassion for those struggling with their health and issues in their lives
  • Strong oral and written communication skills in English
  • Strong oral and written communication in Spanish is preferred but not required
  • Strong organizational and effective time management skills
  • Willingness to advocate for patients in the healthcare setting
  • Willingness to learn new things (such as new computer programs, i.e., Unite Delaware; or new skills)

Minimum Qualifications: High School Diploma or GED. At least two years related experience with community engagement and/or health (i.e., medical assistant, classroom assistant, CHW, outreach worker, volunteer, etc.). Additional education may substitute for required experience.

Preferred Qualifications: 3+ years of experience in working with at risk populations 2+ years residing within Sussex County Previous experience as a CHW and knowledge of community resources highly desirable. CHW Certification 1+ years of knowledge of Medicare/Medicaid population Field based experience: Certified Nursing Assistant / Home Health Aide, or Medical Assistant Bilingual fluency in Spanish and English Experience working in managed care

Competencies Skills: Clear Communication Skills Both Written and Verbal Able to Keep Confidential Information Regarding Patients, Team Members Able to Withstand Crisis Situations Has Skills to Provides Customer Service to Patients, Team Members and Visitors Knowledge And Experience with Electronic Health Records

Credentials: Education: High School Diploma / GED (or higher)

Starting at: USD $18.75/Hr. Beebe Healthcare

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