Population Health Coordinator at Cypress Healthcare Partners

Salinas, California, United States -

Full Time

Start Date

Immediate

Expiry Date

11 Jun, 26

Salary

28.0

Posted On

13 Mar, 26

Experience

2 year(s) or above

Remote Job

Yes

Telecommute

Yes

Sponsor Visa

Skills

Patient Tracking, Follow-up Screening, Liaison, Educational Outreach, Metric Promotion, Interdisciplinary Care Plan Development, Electronic Medical Records Documentation, Scheduling, Pre-visit Planning, Data Collection, Quality Metrics Monitoring, Care Gap Identification, Administrative Duties, Case Management Process, Data Analysis, Program Management

Industry

Hospitals and Health Care

Description

SUMMARY The Population Health Coordinator provides support and oversight for the CCAH, Medi-Cal and Aspire Health Plan (AHP) patient populations. Perform comprehensive tracking and follow-up of patients in need of care establishment with the clinic and in regards to ensuring timely and appropriate follow-up screening. Serve as primary liaison for patients, medical assistants, physicians, and population health staff in regards to the populations served. Organize and assist educational outreach and provide updates regarding progress and procedural changes. Promote awareness of current CCAH and Aspire metrics, purpose and initiatives. ESSENTIAL DUTIES AND RESPONSIBILITIES Includes but not limited to the following: * Work cohesively with various departments throughout Cypress as well as entities including but not limited to Health Information Technology (HIT), Salinas Valley Health Clinics (SVHC), Salinas Valley Hospital (SVH), Central Coast Alliance for Health (CCAH), Aspire Health Plan (AHP) and other at-risk programs. * Contacts, orients and educates new and established patients about SVHC PrimeCare; initiates care plans; provides educational information, updates patient history, obtains necessary medical release information, and updates continuing care requirements. * Develop interdisciplinary care plan (chart) and other case management tools to ensure new and established patient charts are accurate and up-to-date with current and upcoming care gaps. * Ensure proper documentation and health related forms for CCAH and Aspire are within the chart prior to the patients scheduled visit; resolving issues that could affect the care progression; fostering clinic team support; providing education to others regarding the case management process. * Maintains concise documentation in patients’ electronic medical records (EMR) * Scheduling and rescheduling all routine and non-routine medical services for assigned patient population. * Prepare and generate appropriate medical records; generate EMR reports for CCAH and AWV (Annual Wellness Visit) four days in advance according to pre-visit planning guidelines. * Update CCAH checklist and identify patient care gaps; prepare necessary patient folders for scheduled office visit. * Responsible for importing newly enrolled CCAH members monthly to CCAH performance Tracking workbook; ensuring prompt contact with new patient population and scheduling of IHA and/or new patient physical; generating visit worksheet and documentation of identified care gaps. * Follows the CCAH protocol for newly linked members to ensure provider compliance. * Responsible for importing newly assigned Aspire Health plan patient population in the Aspire Performance Tracking workbook; and follows Aspire protocol for newly assigned members. * Responsible for implementing and timely mailing out of monthly Campaigns by following the Monthly Campaigns schedule; Generate call lists and Mailers focused on ensuring streamlined communication and awareness of patient healthcare needs. * Perform a variety of administrative duties including but not limited to: answering phones; faxing and filing of confidential documents; and basic Internet and email utilization. * Analyze, develop and implement improvement activities to increase both provider performance and patient compliance for chosen quality measures. * Responsible for continuously monitoring quality metrics and care gaps by validating quality measures to ensure data accuracy in order to meet goals. * Ensuring timely and accurate reports to ensure follow up regarding defined quality and metric year end targets. * Identify data collection procedures necessary to provide more effective and efficient care while also predicting utilization and other metrics tied to quality of care. * Leads and participates in special projects, as directed; and performs other duties as assigned. * Maintains an expertise of the outpatient practice operations * Maintains a high degree of knowledge in 1. The care management process 2. Working knowledge of the concepts of Medi-Cal managed health care and Medicare Advantage 3. Ability to manage assigned program, including identifying issues and resources, establishing priorities, delegating and coordinating work and assisting with program development 4. Ability to evaluate medical records and other health care data 5. Ability to plan, organize and lead data collection activities 6. NCQA standards and guidelines for Patient-Centered Medical Home level three recognition EDUCATION and/or EXPERIENCE The employee performing this position is expected to hold a High School diploma and have at least 3 years of related healthcare experience involving quality improvement, healthcare quality practices, as well as medical clinic administrative or medical scheduling experience preferred. Three years direct experience in ambulatory care practices in various specialties preferred. Associates degree preferred. PREFERRED Bilingual may be required at certain clinics or during certain shifts. SUPERVISORY RESPONSIBILITIES This job has no supervisory responsibilities. CONDITIONS OF EMPLOYMENT Salinas Valley Health Clinics requires you to prove that you have received the COVID-19 vaccine or have a valid religious or medical reason not to be vaccinated. Proof of identity and legal authority to work in the U.S. is a condition of employment. Cypress Healthcare Partners/Salinas Valley Health Clinics will not sponsor applicants for work visas. The range displayed on this job posting reflects the target for new hire salaries for this position.

Responsibilities

The Population Health Coordinator supports and oversees specific patient populations (CCAH, Medi-Cal, Aspire Health Plan) by tracking patients, ensuring timely follow-up screenings, and serving as a primary liaison between patients, medical staff, and population health teams. This role also involves organizing educational outreach, promoting awareness of current metrics, and developing interdisciplinary care plans to address patient care gaps.