Job Summary

The Population Health Specialist Sr is responsible for outreach to patients with gaps in chronic disease management and preventive care. This role serves to support health status improvement through access to services, education, wellness support and reinforcing the importance of the patient/primary care provider relationship.

Essential Functions

+ Utilizes the Medical Home model to provide targeted outreach to identified patients. Includes current and new patients.

+ Utilizes EMR Systems, registries, health maintenance data, opportunity reports, payer portals and other data as available to validate gaps and conduct outreach activities as assigned.

+ Maintains tracking of outreach and gap closure.

+ Using EMR tools, initiates outreach via EMR portal messages, phone calls, and/or via letters.

+ Updates EMR Systems and payer portals as appropriate.

+ Supports supplemental data submission process for plans...