Population Health Specialist

LifeLong Medical Care is looking for a Population Health Specialist to be based out of our East Oakland Health Center. 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 an entry-level position with a lot of opportunity to learn.

This is a full time, benefit eligible position, working 40 hours/week.

This position is represented by SEIU-UHW. Salaries and benefits are set by a collective bargaining agreement (CBA), and an employee in this position must remain a member in good standing of SEIU-UHW, as defined in the CBA.

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.

Benefits

Compensation: $22/hour. We offer excellent benefits including: medical, dental, vision (including dependent and domestic partner coverage), generous leave benefits including ten paid holidays, Flexible Spending Accounts, 403(b) retirement savings plan.

Responsibilities

• Drive quality assurance and quality improvement of the clinical quality measures, with support from Population Health Program Manager
• Maintain and share dashboard(s) of key processes and outcome measures for use in quality assurance and quality improvement of the clinical quality measures
• Using established protocols and systems, outreach 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. and maintains documentation of contact with patients
• Oversee Social Determinants of Health (SDOH) improvement pilots – e.g., Veggie Give-Away, PRAPARE – and spread within health center, including consistent EHR documentation
• Actively participate and present data in key meetings, professional development, performance coaching, networking, and educational in-services
• Initiate and maintain patient Care Plans, including documentation, collaborating with other members of the patient care team, health coaching for key programs such as Blood Pressure at Home (BPAH)
• Educate, provide resources, and refer patients to additional care services and community services related to their health condition or social determinants
• Establish coordination of care and triage patient requests to Care Transitions panel
• Initiate case conferences with a member(s) of the patients’ care team to address challenges
• Provide onboarding and ongoing training/coaching to other staff e.g., EHR documentation, etc.
• Perform other job-related duties as assigned