Population Health Local Care Director

OB SUMMARY:
The Population Health Local Care Director will be a part of the multidisciplinary healthcare team in the primary care setting. The Population Health Local Care Director will be focused on data collection, closing gaps in care, and assisting in the coordination of care for a panel of patients under the supervision of the Population Health Nurse Manager. The Population Health Local Care Director will promote patient centered care and work collaboratively with primary care providers and the care teams.

MAJOR DUTIES AND RESPONSIBILITIES:

Checking, Examining, and Recording
*Complete pre-visit prep for scheduled patient appointments
*Assist in the tracking of visits with specialists for complex patients

Communication
*Review gaps in care, call patients to communicate gaps and schedule appointments or procedures to close gaps
Obtain records from other providers/labs/diagnostic results as needed for care coordination efforts
*Assist in obtaining medical records and facilitating communication between multiple providers
*Assist with care coordination and communication between multiple providers, both internal and external to Chase Brexton

Analytical and Critical Thinking
*Work to develop systems and processes to support relevant exchange of information to ensure coordination of care, health promotion, and closure of gaps in care
*Work with providers and Population Health nurse(s) to identify high risk, high need, and potentially high cost patients
*Assist care team in implementing best-practice for preventive measures, chronic care, and disease management
*Determine whether screening tests are up to date
*Identify and utilize community resources for patients

Planning and Organizing
*Assist in the monitoring of care to ensure that care is coordinated between specialists, outside providers or other resources
*Assist in monitoring and ensuring that follow up primary care visits are scheduled for ED or inpatient hospital discharges

Workplace Computers and Equipment
*Utilize EMR and Population Health tools to prioritize patient follow-up

Teamwork
*Work with the care team to ensure patient compliance with the care plan

Willingness to Learn
*Attend required training sessions as scheduled

SKILLS AND ABILITIES:
*Critical thinking and reliable decision making skills, ability to escalate issues when appropriate
*Demonstrate self-motivation and the ability to work with a high degree of independence
*Well-organized, good time management
*Excellent interpersonal skills including motivational interviewing skills
*Team oriented
*Proficient in Microsoft Office Suite
*Ability to enter data and check accuracy of detailed work such as correct spelling of names, numbers, dates and time
*Ability to handle multiple tasks at once without mistakes or diminution of professional demeanor and customer service
*Ability to function in high-volume, multiple-task environments - possibly in a closely shared workspace
*Basic understanding of HIPAA and PHI
*Knowledge of medical terminology
*Basic navigation knowledge of electronic medical record applications such as CPS 12 and ability to learn new computer skills