Population Management Coordinator

Explore opportunities with Atrius Health, part of the Optum family of businesses. We're an innovative health care leader and multi-specialty group practice, delivering an effective, connected system of care for adult and pediatric patients at 28 practice locations in eastern Massachusetts. Our entire team of providers (physicians, PA/NPs and ancillary clinicians) works collaboratively with a value-based philosophy within our group practice as well as with hospitals, rehab and nursing facilities. Be part of our vision to transform care and improve lives by building trust, understanding and shared decision-making with every patient. Join us and discover the meaning behind Caring. Connecting. Growing together. As a member of the clinical care team, is responsible for supporting efforts to meet Atrius quality goals by facilitating both routine preventative care and ongoing chronic disease management for primary care patients. Works in a matrix function with overall direction from clinical and administrative leadership at the IM Service Line and the Performance Excellence department, and daily supervision from clinical and administrative leadership at the IM practice site. Identifies and articulates opportunities for work flow changes to improve quality of care related to the organizational strategic quality goals. Understands complex characteristics of the quality metrics and translates the metrics into actionable workflows for the clinical practice. Serves as the organizer and driver of population management outreach work at the site, and plays a key support role for onboarding patients to the practice. Navigates data for large populations of patients to identify recommended clinical care opportunities and subsequently organizes and prioritizes action items, including allocating tasks to the appropriate member of the care team and ensuring efforts are coordinated and avoid duplication. Manages a high volume of patient outreach for patient populations with chronic illnesses (e.g., diabetes, hypertension and cardiovascular disease) as well as for primary care patients needing preventative screening tests within the broader patient population. Builds relationships with patient in order to assist the primary care team in developing an effective and accessible plan of care and ultimately tracks adherence to this plan of care. Note: The role of Population Management Care Facilitator involves complex and detail-oriented responsibilities, the ability to understand and articulate clinical terms and processes and the ability to interact with patients and clinicians about preventative health and chronic disease management. Primary Location : 36 Shops At Five Way, Plymouth, MA. Coverage also required at 2 Technology Park Dr, Bourne, MA Hours : Monday - Friday 8am - 5pm On-Site requirement: Tuesday & Wednesday This position follows an office-based schedule with two in-office days per week.

Coordination/Facilitation/Organization of outreach efforts Serves as a central organizing point within the site for population management activities. Organizes which patients need calls and coordinates who the appropriate person to make the call would be (typically medical assistants or medical secretaries) in an effort to avoid multiple calls to the same patient Collaborates with primary care case management, internal and external specialists, nutrition, social work and insurers as needed Independently review charts, identify or verify care gaps, provide appropriate intervention (e.g. onboarding, outreach, communication to clinician, etc.) Independently contacts patients, clinical and administrative staff and external organizations to gather and relay clinical and care plan information Researches individual patient's clinical information and recommends clinical procedures and tests that are indicated based on standard clinical guidelines Conducts examinations of the clinical record to determine if outreach for identified 'care