Population Health Specialist Job at LifeLong Medical Care
Overview:
This is a full time, benefit eligible position in Berkeley. Bilingual English/Arabic is a plus.
LifeLong Medical Care is a large, multi-site, Federally Qualified Health Center (FQHC) with a rich history of providing innovative healthcare and social services to a wonderfully diverse patient community. Our patient-centered health home is a dynamic place to work, practice, and grow. We have over 15 primary care health centers and deliver integrated services including psychosocial, referrals, chronic disease management, dental, health education, home visits, and much, much more. LifeLong Medical Care is an equal opportunity employer. We strongly encourage applications from women, people of color, and bilingual and bicultural individuals and members of the lesbian, gay, bisexual, and transgender communities. Applicants shall not be discriminated against because of race, religion, sex, national origin, ethnicity, age, disability, political affiliation, sexual orientation, gender identity, color, marital status, or medical condition.
Benefits
COVID-19 Vaccine Policy
Job Requirements
Job Preferences
LifeLong Medical Care is looking for a
Population Health Specialist to be based out of our Ashby Health Center in Berkeley. This position provides Primary Care Providers with dedicated panel management support by proactively identifying patient needs and monitoring and supporting patient follow-up.
This is a full time, benefit eligible position in Berkeley. Bilingual English/Arabic is a plus.
LifeLong Medical Care is a large, multi-site, Federally Qualified Health Center (FQHC) with a rich history of providing innovative healthcare and social services to a wonderfully diverse patient community. Our patient-centered health home is a dynamic place to work, practice, and grow. We have over 15 primary care health centers and deliver integrated services including psychosocial, referrals, chronic disease management, dental, health education, home visits, and much, much more. LifeLong Medical Care is an equal opportunity employer. We strongly encourage applications from women, people of color, and bilingual and bicultural individuals and members of the lesbian, gay, bisexual, and transgender communities. Applicants shall not be discriminated against because of race, religion, sex, national origin, ethnicity, age, disability, political affiliation, sexual orientation, gender identity, color, marital status, or medical condition.
Benefits
We offer excellent benefits including: medical, dental, vision (including dependent and domestic partner coverage), generous leave benefits including nine paid holidays, Flexible Spending Accounts, 403(b) retirement savings plan.
COVID-19 Vaccine Policy
In accordance with LifeLong Medical Care's commitment to provide and maintain a workplace that is free of known hazards, we have adopted a Mandatory COVID-19 Vaccine Policy to safeguard the health of our employees and their families; our patients and visitors; and the community at large from infectious diseases, that vaccinations may reduce. This policy will comply with all applicable laws and is based on guidance from the Centers for Disease Control and Order of the California State Public Health Officer. Unless a reasonable medical or religious accommodation is approved, all employees must receive COVID-19 vaccinations.
Responsibilities:
- Using established protocols and systems, outreaches to patients via phone and face-to-face interaction for chronic condition management or preventive care services, e.g. blood glucose test for diabetic patients, colorectal cancer screening, etc. Maintains documentation of contact with patients
- Oversees social determinants of health (SDOH) improvement pilots – e.g. Veggie Give-Away, PRAPARE – and spread within health center, including consistent EHR documentation
- Actively participates in bi-monthly Population Health peer group meetings at Administration for professional development, performance coaching, networking, and educational in-services
- Within health center-based Complex Care Management Program:
- Identifies and enrolls eligible CCM patients at health center; obtains patient consent to participate in CCM program
- Initiates and maintains patient Care Plans, including documentation, health coaching, and collaborating with other members of the patient care team
- Educates, connects, and refers high-risk patients to additional care services and community services related to their health condition; ensures recommended services were obtained
- Meet with CCM patient to develop Care Plan and continue monthly or otherwise established meetings with CCM patients to continually revise Care Plan according to changes in health status, defined needs, or changes to goals
- Establish one’s self as point of contact for patients on CCM panel, who can then triage patient requests to other members of care team as needed
- Initiate case conferences with a member/members of the patients care team to address challenging or otherwise notable CCM patients
- Provide onboarding and ongoing training/coaching to other members of CCM care team listed in this table to perform CCM duties e.g. EHR CCM documentation
- Maintain and share dashboard of key process and outcome measures for use in quality assurance and quality improvement of CCM Program
- Oversee quality assurance and quality improvement of CCM Program, with support from Population Health Program Manager (Admin)
- Commitment to the provision of primary care services for the underserved with demonstrated ability and sensitivity in working with a variety of people from low-income populations, with diverse educational, lifestyle, ethnic and cultural origins.
- Strong organizational, administrative and problem-solving skills, and ability to be flexible and adaptive to change.
- Ability to effectively present information to others, including other employees, community partners and vendors.
- Ability to work with individuals and organizations at the local level to build support.
- Ability to seek direction/approval on essential matters, yet work independently with little onsite supervision, using professional judgment and diplomacy.
- Work in a team-oriented environment with a number of professionals with different work styles and support needs.
- Excellent interpersonal, verbal, and written skills.
- Conduct oneself in internal and external settings in a way that reflects positively on LifeLong Medical Care as an organization of professional, confident and sensitive staff.
- Ability to see how one’s work intersects with that of other departments of LifeLong Medical Care and that of other partner organizations.
- Make appropriate use of knowledge/ expertise/ connections of other staff.
- Be creative and mature with a “can do”, proactive attitude and an ability to continuously “scan” the environment, identifying and taking advantage of opportunities for improvement.
Job Requirements
- Bachelor’s Degree or equivalent combination of experience and education.
- Minimum one year experience with essential duties or duties similar to the above.
- Experience retrieving, organizing and assessing quantitative data.
- Proficient in Microsoft office suite
Job Preferences
- Experience working for a non-profit community health clinic and/or social service organization.
- Electronic Health Records experience
- Working knowledge of community health problems including social and economic factors impacting health status.
- Experience and sensitivity working with low-income populations, substance users, and/or psychologically impaired persons.
- Experience in data analysis, health coaching, nutrition, adult education, group facilitation and/or patient outreach.
- Bilingual English/Arabic
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