Job Description JOB SUMMARY: The Population Health Specialist will collaborate with and support providers and practice support staff to improve population health performance and achieve quality incentives. Will develop relationships with external stakeholders such as insurance companies, regulatory and oversight agencies and develop processes to execute and ensure compliance with various population health projects. Promote quality improvement and population health management. Reports directly to the Executive Director of Quality. DUTIES AND RESPONSIBILITIES: Collaboration/ Coordination: 1. Works collaboratively with the CIS department, MIS department, and users of the clinical information systems to ensure data is in the proper fields for reporting. 2. Develops and maintains a positive working relationship with end user departments to ensure optimal utilization of the ambulatory EHR while supporting training processes and protocols. 3. Analyzes current requirements and makes recommendations for application changes that support and improve workflows and practice operations, while documenting and reporting necessary information. 4. Some travel to AMS offices may be required for education, support and review of processes. 5. Assists with DSRIP and population health initiatives as they relate to patient care and documentation. Works with EMR team and Directors to make recommendations for workflows to implement requirements of various projects. Quality Improvement: 6. Reviews registries with providers and/or key office staff to identify care gaps and opportunities for outreach and/or gap closure. 7. Develops a process for routine reporting and provides routine feedback to providers and staff on compliance with various programs. 8. Facilitates pre-visit planning, pre-gap closure initiatives, referral tracking and closure etc. to improve population health. 9. Participates in complex projects, conducting observations and process analysis to identify opportunities. 10. Manages project budget and maintains an electronic filing system of project finances and deliverables.as requested 11. Develops and reviews contracts and other funds flow documents to ensure accuracy/legitimacy. Involves others in approval process as required. Data Collection: 12. Is familiar with various clinical quality initiatives and requirements for data collection and reporting. Including but not limited to PCMH, DSRIP and Medicare Wellness exams. 13. Conducts routine audits of documentation to ensure compliance with protocols and standardized workflows. Provides feedback to directors with recommendations for improvement and areas of opportunity to improve population health and maximize incentives. 14.Assist in auditing of practices to ensure compliance with PCMH standards (same day appointments, daily huddles, meetings etc.) 15. Extracts data from practice EMR and Arcadia to identify care gaps and monitor quality score performance. 16. Uses a variety of databases to pull and validate data for the pay for performance, quality improvement activities, PCMH initiatives and DSRIP initiatives. 17. Tracks and monitors and assesses quality scores and performance related to chronic disease management (diabetes, CVD, Hypertension etc.) and patient outcomes.as requested 18. Reviews, validates and reports data to the various registries as required. 19. Prepares population health data as required for review by state and federal regulators, NCQA reviewers etc. Knowledge Base: 20. Identifies and researches quality program initiatives and makes recommendations to Executive Director of Quality and CMIO with implementation strategies. 21. Attends training sessions, webinars, and educational meetings regarding quality initiatives to expand knowledge and stay current with best practices. Administrative Responsibilities: 22. Employee will have advanced skills with Microsoft applications specifically Excel and have the ability to produce complex documents, perform analysis and maintain databases. 23. Must be familiar with all electronic health applications and programs and will generate monthly reports as required for PCMH, Case management, DSRIP initiatives etc. Other: 24. Is responsible for attending all annual mandatory educational programs as required by position. 25. Employee understands and demonstrates the importance of satisfying the needs of the customer/patient by interacting with him/her in a friendly and caring way, being attentive to the customer’s needs, both psychologically and physically, and by taking the initiative to maintain communication with the customer in order to provide a secure and pleasant experience with the Medical Center. 26. It is understood that this job description lists typical duties for the classification and is not to be considered inclusive of all duties which may be assigned. EDUCATION: High school diploma required. Medical terminology preferred. EXPERIENCE: Three (3) years experience in a healthcare setting. QUALIFICATIONS: Advanced knowledge of Microsoft applications specifically Excel. CARDIOPULMONARY RESUSCITATION (CPR) REQUIREMENTS: No CPR required. PHYSICAL DEMANDS: Typical office duties with light physical efforts. Travel to AMS practice offices may be required. EXPOSURE CATEGORY: Non-Direct Patient Care Category III. Tasks that involve no exposure to blood, body fluids, or tissues. And Category I tasks are not a condition of employment. Requirements