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Population Health Specialist


Department Description: This role is providing support on the Beth Israel Lahey Health Performance Network.

Job Location: Wakefield, MA

Req ID: 32434BR


Job Summary: Under the supervision of the Quality Manager, the Population Health Specialist (PHS) supports collaboration, communication and care coordination with all members of the health care team, including but not limited to POD leaders, practices, clinicians and hospital leadership. The PHS is the primary point of contact with and an integral member of the health care team. They will work to ensure safety, best practice and high quality standards of care across the health care continuum to achieve the quality incentives as part of global payment and managed care contracts with the goal of optimizing our patients' health and well-being, ensuring that contractual metrics are met, and maximizing financial revenue in our quality risk arrangements. This role is responsible for the communication of targets for medical expense trend and quality outcomes and the facilitation of activities to meet identified targets through analysis of quality, cost and utilization reports. Assists the health care team in implementing and using systems and interventions to improve patient care and outcomes by identifying key drivers of performance and implementation of project plan(s) initiatives to impact those key drivers.

Essential Responsibilities:
  1. Serves as subject matter expert on HEDIS ambulatory quality measures and uses that knowledge to effectively communicate information as the central resource to assigned hospital, POD leaders, physician groups and clinical teams participating in the BILPN risk arrangement quality programs.
  2. Acts as a key resource to practice(s) for the management of registries of patients that have chronic diseases to ensure they have the required testing and medication management to promote optimal health and clinical outcomes. Ensures pre-visit planning, reminders and processes on day of visit and subsequent tests and referrals following visits to improve population health.
  3. Works collaboratively with practice/providers to develop campaigns to address gaps in care, monitors patient and practice/provider compliance with campaigns and provide feedback and adjustment as needed to ensure success.
  4. Supports process improvements to enhance clinician and staff workflows by identifying potential barriers and making recommendations on improvement initiatives. Audits performance based on recommendations and evaluates compliance and engagement. Effectively communicates key findings to drive informed decision making.
  5. Provides expertise, training, and ongoing support for quality measures and the EHRs and related clinical and technical systems which support the collection and tracking of such measures.
  6. Performs monthly review of key analytic reports to track overall POD and provider performance by extracting data from the analytic tool(s) and practices' electronic medical record. Ensures POD, practices, and clinicians are informed on current performance and areas of opportunity for improvement.
  7. Provides an effective communication link between POD leaders, practices and clinicians and BILPN leadership. Escalates issues and/or concerns with practice engagement, participation or performance to quality manager and medical director as needed.
  8. Identifies and communicates best practice opportunities to POD leaders, practices, clinicians and team members to help improve performance. Participates in team decisions regarding data requirements for pro-actively managing the team's panel.
  9. Participates as necessary on payer audits for numerator compliance and exclusions on quality measures.
  10. Coordinates with Manager of Quality to track and share data with practice on patient experience improvement measures and performance against goals. And performs other duties as assigned.
Required Qualifications:
  1. Associate's degree required. Bachelor's degree preferred.
  2. 3-5 years related work experience required.
  3. Bachelor's degree, Medical Assistant Certification or minimum 3-5 years related experience in a health care environment.
    Knowledge of medical terminology.
  4. Strong knowledge of and experience with HEDIS ambulatory quality measures. Must be able to travel to offsite meetings at various provider practices and hospitals.
  5. Demonstrates, after receipt of training, ability to use all applicable electronic systems/applications such as Patient Registry, EHR and population management systems to input, retrieve, and manipulate clinical information, patient registration and appointment information. Must be highly attentive to detail, accuracy, and achieving end results.
  6. Advanced skills with Microsoft applications which may include Outlook, Word, Excel, PowerPoint or Access and other web-based applications. May produce complex documents, perform analysis and maintain databases.
Preferred Qualifications:
  1. Knowledge of process improvement initiatives such as LEAN or Six Sigma. Knowledge of electronic medical records; eClinical Works, Athena, GE Centricity or Epic.
Competencies:
  1. Decision Making: Ability to make decisions that are guided by general instructions and practices requiring some interpretation. May make recommendations for solving problems of moderate complexity and importance.
  2. Problem Solving: Ability to address problems that are varied, requiring analysis or interpretation of the situation using direct observation, knowledge and skills based on general precedents.
  3. Independence of Action: Ability to follow precedents and procedures. May set priorities and organize work within general guidelines. Seeks assistance when confronted with difficult and/or unpredictable situations. Work progress is monitored by supervisor/manager.
  4. Written Communications: Ability to communicate clearly and effectively in written English with internal and external customers.
  5. Oral Communications: Ability to comprehend and converse in English to communicate effectively with medical center staff, patients, families and external customers.
  6. Knowledge: Ability to demonstrate full working knowledge of standard concepts, practices, procedures and policies with the ability to use them in varied situations.
  7. Team Work: Ability to interact respectfully with other employees, professional staff and/or external contacts to offer ideas, identify issues, obtain information or deliver services.
  8. Customer Service: Ability to provide a high level of customer service to patients, visitors, staff and external customers in a professional, service-oriented, respectful manner using skills in active listening and problem solving. Ability to remain calm in stressful situations.

Physical Nature of the Job:
Sedentary work: Exerting up to 10 pounds of force occasionally in carrying, lifting, pushing, pulling objects. Sitting most of the time, with walking and standing required only occasionally

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