Job Category:

Physician Services / Physician Clinics

Work Shift/Schedule:

8 Hr Morning - Afternoon

Northeast Georgia Health System is rooted in a foundation of improving the health of our communities.

About the Role:

Job Summary

Population Health Specialists support the development of patient-centered, team-based care through collaboration with primary care providers (PCPs) and their practices. This role assists practices in managing their panel of patients by identifying patients’ unmet needs, facilitating access to appropriate care including preventive services and chronic disease treatments, engaging patients in their own care, and enhancing communication between patients and their care teams.

Minimum Job Qualifications

• Licensure or other certifications: MA Certification or equivalent experience in healthcare.

• Educational Requirements: High School Diploma or Equivalent.

• Minimum Experience: 5 years direct healthcare experience and 2 years direct population health experience

• Other:

Preferred Job Qualifications

• Preferred Licensure or other certifications: LPN Preferred

• Preferred Educational Requirements: Associates preferred.

• Preferred Experience:

• Other:

Job Specific and Unique Knowledge, Skills and Abilities

• Excellent communication (verbal and written) and presentation skills to provide outstanding, personalized customer service and to instill confidence and to advocate for patients; ability to explain required information to patients in a comprehensible manner.

• Ability to develop strong, trusting relationships with leadership, physicians, pharmacists, and patients in the value-based programs.

• Highly organized, work autonomously, self-motivated with the ability to adapt to various workspaces. Self-direct through multitasking and prioritizing.

• Proficient with Microsoft Office applications (Word, Excel, Outlook, PowerPoint).

• Other professional skills and qualities: strong attention to detail, dependability, empathy, focus on quality, goal-oriented, ability to delegate and direct others, outstanding phone etiquette. 

• Must practice discretion and confidentiality as position deals with highly sensitive and private data.

Essential Tasks and Responsibilities

• Identifying high risk/target patient populations and developing tactics to help practices manage these groups. Use the EMR and other methods to facilitate care coordination and effective communication with patients and outreach to them.

• Ensuring complex care management/coordination activities and timely adherence to disease specific, evidence based guidelines for all chronic conditions as well as preventative and curative care measures.

• Serving as a liaison between the patient, their family and their Longstreet Clinic care team

• Coordinating care within the healthcare delivery system including inpatient facilities, ED’s,  and ancillary services

• Effectively uses the following tools/strategies that include, but are not limited to: health risk assessments, predictive models (algorithm-driven models that use multiple inputs to predict high-risk opportunities for case management), surveys (e.g., PHQ-9, Short Form 12), case findings (e.g., chart reviews, surveys), referrals (from patients, providers, community).

• Assisting in data collection, management, and patient outreach as needed for target patient populations

• Identify care gaps and support clinical team in outreach efforts

• Creating a positive experience for patients and families through courteous interactions via phone, patient portal and in-person, as well as appropriate and efficient routing and referrals to clinical staff or other practices when necessary

• Contributing to quality improvement and meeting requirements for achieving/maintaining NCQA practice and provider recognitions for (but not limited to) Patient-Centered Medical Home, Diabetes Recognition and Heart/Stroke Care Recognition

• Maintain current awareness and understanding of quality measures; reporting quality and performance improvement initiatives; establish and monitor performance goals and improving overall patient care metrics

• Anticipates needs of the patient population, identifying and developing programs to support care management, patient education and self-management activities

• Reporting to Population Health Manager productivity goals and performance

• Work with Population Health Manager in maintaining payer contract quality initiatives

• Attending and participating in regular meetings with the Population Health Team as well as within other departments (clinical and non-clinical) and practices as needed

• Participates in the development/review/revision of standard work and related policies and/or procedures for Care Manager services.

• Actively participates in required offsite health fairs and other community events as assigned

• Other duties as assigned

Physical Demands

• Weight Lifted: Up to 50 lbs, Occasionally 0-30% of time

• Weight Carried: Up to 50 lbs, Occasionally 0-30% of time

• Vision: Moderate, Frequently 31-65% of time

• Kneeling/Stooping/Bending: Occasionally 0-30% of time

• Standing/Walking: Occasionally 0-30% of time

• Pushing/Pulling: Occasionally 0-30% of time

• Intensity of Work: Occasionally 0-30% of time

• Job Requires: Reading, Writing, Reasoning, Talking, Keyboarding, Driving

Working at NGHS means being part of something special: a team invested in you as a person, an employee, and in helping you reach your goals. 

NGHS: Opportunities start here.

Northeast Georgia Health System is an Equal Opportunity Employer and will not tolerate discrimination in employment on the basis of race, color, age, sex, sexual orientation, gender identity or expression, religion, disability, ethnicity, national origin, marital status, protected veteran status, genetic information, or any other legally protected classification or status.