Population Health Outreach Specialist (LPN/MA) - PHSO - Full-time - Remote

at  MercyOne

DESCRIPTION:

PHSO Population Health Outreach Specialist (LPN/CMA)
Reporting to: PHSO Quality Manager
Supervisory Responsibility: N/A
FLSA Status: Non-Exempt, Hourly
Department: MercyOne System Office, Care Management and Quality
Effective Date: 01/28/2021
Mission Statement: MercyOne serves with fidelity to the Gospel as a compassionate healing ministry of Jesus Christ to transform the health of our communities.
MercyOne Vision Statement:
MercyOne will set the standard for a personalized and radically convenient system of health services.
MercyOne Cultural Beliefs:
Be ONE
I benefit from and strengthen MercyOne.
Personalize Care
Your experience. My responsibility.
Own It!
I own my actions to deliver our key results.
Improve Daily
I make improvements every day for those we serve including each other.
Innovate
I imagine and embrace bold new ideas to revolutionize health.
Job Summary: The Population Health Outreach Specialist works as an integral part of an interdisciplinary team to proactively identify patients due or over-due for specific health services. The Outreach Specialist contacts patients, motivates patients to complete recommended health care services and assists in scheduling appointments. The Outreach Specialist supports Population Health patients by closing gaps in recommended clinical care, performing chart reviews, and managing the disease registry.
Essential Position Expectations:
1. Utilizes standardized tools and scripting to conduct patient outreach to patients to schedule and coordinate preventative health care services such as Annual Wellness Visits, cancer screenings, immunizations, and chronic disease interventions.
2. Conducts pre-visit chart review focusing on closing gaps in care and complete, accurate risk coding.
3. Manages CMS web interface quality reporting annually. Supports additional quality reporting requirements of PHSO contracts as needed.
4. Conducts outreach to patients with medication adherence deficits utilizing the PHSO’s standard medication adherence patient assessment.
5. Identifies and refers high risk patients to the PHSO ambulatory care management team for care coordination services.
6. Practices motivational interviewing to support health behavior change.
7. Requests documents from outside facilities needed to support care gap closures.
8. Oversees the PHSO’s disease registry assuring the database is up to date, accurate and conducting manual data entry when required.
9. Accepts referrals from care management team members to assist with the above position expectations.
10. Answers patient questions regarding appointments and/or testing. Addresses potential barriers to care and collaborates with Provider to answer patient questions and concerns that fall outside of scope.
11. Documents all patient interactions in the patient’s health record or care management documentation system immediately after the call or meeting is completed. The maximum allowable time from interaction to documentation is one business day.
12. Supports and participates in PHSO quality improvement activities at the direction of the quality manager.
Knowledge & Skills:
1. Ability to deal with confidential and sensitive information, requiring ongoing discretion and management of secure information.
2. Strong communication (verbal/written) and organizational skills and ability to interact effectively with providers, clinic staff, and care management team members across the care continuum.
3. Demonstrated capacity to problem solve and prioritize in complex situations.
4. Adaptability to performing a variety of duties, often changing from one task to another of a different nature without loss of efficiency or composure.
5. Ability to function effectively in a team based environment.
6. Basic Excel and Word skills.
7. Ability to understand and apply guidelines, policies and procedures.
8. Obtain Certificate of Competency in Population Health Care Management within 12 months of hire.
9. Proof of completion of Mandatory Reporter within three months of hire.
Mental & Physical Demands:
1. Must be able to pass a pre-employment drug screening test at time of hire.
2. Work onsite with regular and predictable attendance.
3. Maneuver within the physical work environment with some bending, stooping, reaching, and light lifting.
4. Constantly able to use hands and fingers to type, write, and file. Frequently able to use near vision for viewing computer monitor and written materials. Occasionally required to detect unusual odors that could indicate environmental issues.
5. Use of usual and customary equipment used to perform essential functions of the position.
Education: Associates degree preferred.
Experience: Minimum of 3 years health care experience. Varied clinical experience preferred.
Certifications & Licenses: Iowa state licensure as a Licensed Practical Nurse (LPN) or Certified Medical Assistant (CMA).

MINIMUM QUALIFICATIONS:

• Graduate of an accredited nursing program or an accredited Medical Assistant program.
• If graduate of accredited nursing program- current license and/or certification in accordance with education; if Med Asst-certification preferred.
• Certificate of Competency in Population Health Care Management within 12 months of hire.
• Minimum of 3 years health care experience. Varied clinical experience preferred.
• BLS, Mandatory Reporter
• Ability to deal with confidential and sensitive information, requiring ongoing discretion and management of secure information.
• Demonstrated capacity to problem solve and prioritize in complex situations.
• Adaptability to performing a variety of duties, often changing from one task to another of a different nature without loss of efficiency or composure.

POSITION PURPOSE:

Works as an integral part of an interdisciplinary team to proactively identify patients due or over-due for specific health services. Contacts patients, motivates patients to complete recommended health care services and assists in scheduling appointments. Supports Population Health patients by closing gaps in recommended clinical care, performing chart reviews, and managing the disease registry. Adheres to MercyOne’s performance expectations and performs all defined services and other related duties in accordance with the mission, vision, and values of MercyOne.

WHAT YOU WILL DO:

• Utilizes standardized tools and scripting to conduct patient outreach to patients to schedule and coordinate preventative health care services such as Annual Wellness Visits, cancer screenings, immunizations, and chronic disease interventions.
• Conducts pre-visit chart review focusing on closing gaps in care and complete, accurate risk coding.
• Manages CMS web interface quality reporting annually. Supports additional quality reporting requirements of PHSO contracts as needed.
• Conducts outreach to patients with medication adherence deficits utilizing the PHSO’s standard medication adherence patient assessment.
• Identifies and refers high risk patients to the PHSO ambulatory care management team for care coordination services.
• Oversees the PHSO’s disease registry assuring the database is up to date, accurate and conducting manual data entry when required.
• Documents all patient interactions in the patient’s health record or care management documentation system immediately after the call or meeting is completed. The maximum allowable time from interaction to documentation is one business day.