Population Management Coordinator

Atrius Health is a nonprofit healthcare leader delivering a system of connected care that enables us to know our patients better so that we can serve them well. Across 32 clinical locations, more than 50 specialties and 825 physicians, we provide proactive, customized care to more than 720,000 adult and pediatric patients across eastern Massachusetts.

The Atrius Health practices including Dedham Medical Associates, Granite Medical Group, Harvard Vanguard Medical Associates and PMG Physician Associates – together with VNA Care – work in collaboration with hospital partners, community specialists and skilled nursing facilities, to develop innovative and effective ways of delivering care in the most appropriate setting, making it easier for patients to be healthy.

We believe that by establishing a solid foundation of knowledge, understanding and trust with each of our patients, we enrich their health and enhance their lives.

SUMMARY

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.

EDUCATION/LICENSES/CERTIFICATIONS

High School diploma or equivalency certificate (e.g. GED, HiSET, TASC Test) from an accredited institution or governmental unit required. Associates Degree or some college preferred. Degree in healthcare field preferred.

EXPERIENCE

Skills and experience typically acquired through three years (one of which is calculated from degree) in a: clinical business support, or clinical research, or ambulatory care setting, or customer service business. Previous training or experience in population health management preferred.

SKILLS

Proficiency in the proven ability to extract data and manipulate spreadsheets, and/or understand and utilize principles of data analysis required. Proficiency in Microsoft Office. Strong interpersonal skills required with the ability to build productive relationships with physicians, other professionals, internal staff and patients. Comfortable in sharing information in a positive and encouraging manner. Proven ability to deal with conflict. Excellent time management and organizational skills required with the ability to manage multiple quality projects/initiatives. Ability to work with a high degree of detail in a busy and demanding environment. Must possess effective communication skills both verbal and written, in the English language. Excellent phone skills, strong customer service and ability to build relationships with patients by phone are required. Ability to work independently as well as within the network for the clinical department and the larger population management coordinator group. EMR experience and/or aptitude to master the EMR based on proficiency in other technology experience required.

Knowledge and understanding of medical terminology strongly preferred. Proficiency in Excel strongly preferred.

Atrius Health is committed to a policy of non-discrimination and equal employment opportunity. All patients, employees, applicants, and other constituents of Atrius Health will be treated with respect and dignity regardless of race, national origin, gender, age, religion, disability, veteran status, marital/domestic partner status, parental status, sexual orientation and gender identity and/or expression, or other dimensions of diversity.

Benefits Include:

• Up to 8% company retirement contribution,

• Generous Paid Time Off

• 10 paid holidays,

• Paid professional development,

• Generous health and welfare benefit package.