Population Health Care Coordinator

Department Overview

The Population Health Care Coordinator plays a critical role in helping OHSU, Adventist and Hillsboro Medical Center manage value based patient populations by ensuring outreach to patients in need of preventative care, the scheduling of annual chronic disease review visits, and engagement of new patients under value. Reporting to the Director of Population Health, this role regularly reviews payer data, rosters, and epic registries to identify patients in need of outreach and escalates barriers appropriately. They have a consistent focus on advancing health equity through this outreach and help inform Population Health and operational leaders on barriers encountered by patients in order to shape future workflow development and improve care provided to patients in the Portland Metro Area. The Care Coordinator will act as an expert on standard care gap workflows maintaining a close connection to locally embedded staff to avoid duplication and remain patient centered. The Population Health Care Coordinator is a value based care champion and works to shape culture and improve patient care in all they do. This position is called upon to work independently with minimal supervision.

Pay Range: $24.62 - $33.28 per hour

Function/Duties of Position

Preventative Care Gap Outreach

• Leverages epic reporting workbench reports, care gap lists from payers and other data sources identifying patients overdue for preventative gaps in care places orders under delegated protocol, and outreaches to patients via phone, letter, or mychart; documenting all work in epic.
• Regularly review key quality metric dashboards to inform prioritization of outreach and work.
• Collaborates closely with local Care Coordinators, operational leaders and Office of Primary Care & Population Health staff to avoid duplication and ensure patient centered outreach.
• Maintains a log of barriers encountered; summarizes and presents report to Director of Population Health and Pop Health PIC monthly.
  
  

HCC Care Gap Closure & Outreach

• Leveraging payer and epic based registries will proactively outreach to new patients and existing patients who have a Primary Care provider but have not been seen in the last year in order to ensure appropriate chronic diseases are addressed by their Primary Care Provider.
  
  

Patient Outreach, Engagement, And Scheduling

• Leverages epic registries and payer reports to regularly identify new patients assigned to practices not yet seen, outreaches to them to offer them an appointment to establish care with a medical home across HMC, OHSU, and AH and schedules accordingly.
• Understands and identifies vulnerable patient populations who are established but disengaged in care, outreaches to understand key social determinant barriers (e.g transportation, housing) and partners appropriately with local teams and IDS care coordinator team members to address these and connect to care
  
  

Required Qualifications

• 2-5 years’ experience in a clinical setting with focus on front desk and/or Medical Assistant duties.
• Knowledge of Epic: Cadence or Epicare or both.
• Keen observation skills; excellent written and verbal communication skills.
• Ability to persuade and influence effectively.
• Superb problem solving skills.
• Knowledge of Microsoft: Excel and Word.
• Ability to work under pressure and to prioritize among competing problems/issues.
• Ability to exercise good judgement, act independently with limited day to day supervision.
• Ability to perform the job duties with or without accommodation.
  
  

Preferred Qualifications

• CMA certification
• Bachelor’s degree
• 2 years’ experience in an outpatient setting with insurance training and/or experience.
  
  

All are welcome

Oregon Health & Science University values a diverse and culturally competent workforce. We are proud of our commitment to being an equal opportunity, affirmative action organization that does not discriminate against applicants on the basis of any protected class status, including disability status and protected veteran status. Individuals with diverse backgrounds and those who promote diversity and a culture of inclusion are encouraged to apply. To request reasonable accommodation contact the Affirmative Action and Equal Opportunity Department at 503-494-5148 or aaeo@ohsu.edu.

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