Preventative Health Coordinator - West Region

To be part of our organization, every employee should understand and share in the YNHHS Vision, support our Mission, and live our Values. These values - integrity, patient-centered, respect, accountability, and compassion - must guide what we do, as individuals and professionals, every day.

The Preventive Health Coordinator is as a member of the Ambulatory Care Management team and is accountable for improving the health outcomes of the populations served. The Preventive Health Coordinator works as part of a multi-disciplinary team under the direction of the Ambulatory Care Management leadership, supporting multiple primary care practices, and certain specialty metrics. The Preventive Health Coordinator is responsible for supporting quality improvement and patient outcome goals by reviewing records and other data sources to identify opportunities for outreach and preventive activities, specifically related to Care Gap Closure and to support the CIN in provider education and care gap closure best practices. The role includes reviewing registry and/or payer lists to identify any outstanding preventative services or other gaps in care and proactive outreach to patients to discuss and/or schedule Annual Wellness Visits (AWVs), preventive cancer screenings, medication adherence, and chronic disease management for conditions such as hypertension and diabetes. Other metrics of priority to be assigned per value based contract agreements. During proactive outreach to patients, PHCs will identify barriers to care & connect patients to appropriate care management staff for further care management functions, as needed. Extensive collaboration with other clinic staff across the CIN is expected to create systems that promote preventive care completion and emphasis on quality improvement. It is expected for the team members to maintain a recurring onsite presence in their assigned practices, to build relationships, support care teams, and drive population health initiatives.

EEO/AA/Disability/Veteran

• Demonstrates an understanding of clinical standards, quality performance goals and expected outcomes.
  • Completes all administrative functions associated with closing gaps in care in a timely manner, including interpreting reports from payers and routes to appropriate members of the health care team.
  • Demonstrate and apply knowledge of the philosophy/principles of comprehensive, patient-centered, developmentally appropriate, and culturally sensitive patient care.
  • Display comfort and interest working with patients around issues of healthcare access and adherence to clinical practice guidelines.
  • Assists the health care team in educating the patient during telephonic outreach on the importance of compliance with evidence-based guidelines.
  • Demonstrates skill in navigating the electronic medical records and maintains confidential records and is HIPAA compliance in their work.
  • Under the guidance of clinically licensed staff, facilitates outreach and follow up for quality improvement initiatives such as medication adherence, hypertension control, and other clinical goals as identified by ACM and Population Health leadership.
• Demonstrates knowledge of available patient support, including technology and resources.
  • Uses patient identification reports to conduct outreach to patients identified as needing screening, follow-up and preventive care services and educates on the importance of compliance using motivational interviewing skills.
  • Uses independent judgment prioritizes appropriately to ensure efficient utilization of time.
  • Facilitates appropriate routing or referrals under the direction of licensed staff.
  • Collects and synthesizes data from electronic medical records, population health dashboards, and other sources to support work within the
    department.
  • Provides support of population health tools that enhance communication and awareness across multiple departments
• Demonstrates an ability to serve as a collaborative member of a multidisciplinary healthcare team.
  • Accountable for consistently communicating and building strong relationships with members of the Ambulatory Care Management, Population Health and Practice staff and clinicians to collaborate on implementing effective systems of preventive care and population health.
  • Assists care management team to evaluate and redirect the current patient plan of care in order to streamline the delivery of service.
  • Contacts and coordinates with referral agencies to arrange provision of associated services when appropriate and as directed by Care Management team.
  • Collaborates across Ambulatory Care Management structure and programs to aid care teams in closing gaps in care
  • Facilitates, plans, and supports education sessions necessary to support the goals and objectives of the department, collaborating with internal and external stakeholders.
  • This role requires a dynamic individual that excels in clinic work, care management work, patient experience work, referral work, reporting work, and clerical work.
• Additional duties as assigned.

EDUCATION

• High school diploma required. Associate's and/or Bachelor's Degree preferred.

EXPERIENCE

• Minimum of 3 years' experience in a healthcare setting required. Experience in ambulatory and/or primary care is preferred.

SPECIAL SKILLS

• Motivational interviewing skills necessary.
• Excellent verbal and written communication skills.
• Possesses excellent organizational skills and ability to handle multiple priorities.
• Ability to work in an independent role with minimal supervision.
• Ability to work collaboratively with health care professionals at all levels to achieve established goals and improve quality outcomes.
• Working knowledge of computers and basic software applications used in job functions, such as word processing, databases, spreadsheets, and others as needed

PHYSICAL DEMAND

• Role is a hybrid work position with the expectation to travel to assigned onsite practice locations on a recurring schedule and/or as requested by management. Ability to attend initial onsite orientation and onboarding program as well as monthly onsite training obligations. Adheres to all organizational remote worksite standards.