Population Health Advocate

1 month ago

Albuquerque, New Mexico, United States First Choice Community Healthcare Full time
Job Title: Population Health Advocate

First Choice Community Healthcare is seeking a highly motivated and detail-oriented Population Health Advocate to join our team. As a key member of our healthcare team, you will play a vital role in improving the health, life skills, and wellbeing of our patients.

Job Summary:

The Population Health Advocate will be responsible for reviewing patient registries and other data sets to identify gaps in care, disease-specific screenings, and basic preventative health screens. You will communicate with patients and/or clinic staff to ensure timely closure of identified gaps and document activities/interventions within patient charts or other reporting formats.

Key Responsibilities:
  • Reviews patient registries and other data sets to identify gaps in care, disease-specific screenings, and basic preventative health screens.
  • Communicates with patients and/or clinic staff to ensure timely closure of identified gaps.
  • Documents activities/interventions within patient charts or other reporting formats.
  • Collects and tracks monthly, quarterly, and annual process improvement/quality measure data.
  • Conducts analysis of data in collaboration with care teams to assist in identification of improvement activities.
  • Presents data collected in an organized format to facilitate analysis and identification of improvement opportunities.
  • Accesses daily reports to identify patients hospitalized, discharged, and treated in the Emergency Department (ED).
  • Provides assistance with care coordination, facilitates communication between patients, caregivers, and providers, helps to address barriers to care, and promotes optimal allocation of resources.
  • Provides information to patients and families regarding community resources, medication assistance, and other healthcare needs.
  • Implements/assists with a variety of healthcare quality improvement/population health activities, as indicated and directed.
  • Participates in the development, implementation, and/or evaluation of FCCH PCMH initiatives.
  • Conducts patient chart reviews for pre-visit planning using standard protocols to enhance visit efficiency and effectiveness.
  • Assists patients with scheduling, ordering lab work, and/or testing that may be needed for a chronic disease as defined in the organizational standard protocols.
  • Participates in patient outreach (via phone, virtual platform, clinic, and/or home visit) to achieve greater patient compliance with appropriate treatment plans, standards of care/protocols, and improved patient healthcare outcomes.
  • Supports patients in an effort to make them successful while following the written plan of care, as indicated in the discharge plans and ambulatory care plan.
  • Encourages patients to use self-management tools as provided.
  • Facilitates patients' access to available community support, educational, and/or other healthcare resources, as appropriate to their needs and according to any requirements of health insurance or healthcare financial assistance programs they may (or may not) have.
Requirements:
  • Minimum of two (2) years' recent experience in a healthcare setting required.
  • Current medical assistant or equivalent experience.
  • Experience and knowledge of electronic health records required.
  • Knowledge of medical terminology, CPT, and ICD-10 codes required.
  • Ability to communicate effectively and maintain cooperative relationships with providers, staff members, patients, and the medical community.
  • Ability to employ tact, diplomacy, and compassion with all types of people.
  • Strong research and analysis skills highly preferred.
  • Must successfully function in a fast-paced, service-oriented environment.
  • Must have strong organizational skills, be detail-oriented, a self-starter, possess ability to set priorities, and function as part of a team.
  • Possess ability to use good judgment, maintaining confidentiality at all times.
  • Possess and maintain computer skills to include working knowledge of Word, Outlook, Excel, and the ability to learn other software as needed.
  • Experience with data analytics and quality metrics preferred.
  • Knowledge of community resources preferred.
  • Working knowledge of and ability to implement appropriate standing orders and care management practices.
  • Strong interpersonal, resource development, research, and communication skills and the ability to work as an effective team member with a wide range of medical and administrative staff and outside entities, as well as a diverse patient population.
  • Ability to communicate complex information in a manner easily understood by diverse listeners and strong customer service skills.
  • Ability to speak clearly and concisely.
  • Ability to read, understand, provide, and follow verbal and written instruction.
  • Ability to establish and maintain effective working relationships with patients, employees, community partners, and the public.
  • Ability to function independently/autonomously while maintaining effective and necessary communication with Director.
  • Knowledge and familiarity with compliance programs, cooperate fully and comply with laws and regulations, including HIPAA.
  • Bilingual English/Spanish is highly preferred.
Physical Characteristics/Working Conditions:
  1. Physical Effort and Dexterity: Good dexterity to operate personal computer and office equipment. Occasional lifting and carrying related to office duties.
  2. Machines, Tools, Equipment required to be operated: Capable of using office machines and personal computers for word processing, data entry, and spreadsheet applications.
  3. Visual Acuity, Hearing, and Speaking: Must be able to read a computer monitor and outputs accurately. Must be able to communicate clearly and accurately for work and safety compliance.
  4. Environment/Working Conditions: Work is mostly inside a clinical office setting in a controlled environment. Normal clinical/office safety precautions and practices are required. Position may require travel throughout the greater Albuquerque metropolitan area. Work is regularly scheduled Monday-Friday, although weekends may be required to meet deadlines.

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