SBH Health System

The Population Health Coordinator designs and implements clinical data activities and population health programs to improve patient care. The Coordinator carries out performance improvement and population health activities across Ambulatory Care, Emergency Department and Inpatient settings. They collaborate with stakeholders to gather data, run analytic reports, and interact directly with patients to improve their health. This includes reviewing patient charts to identify gaps in care, completing patient text message and telephone campaigns, and meeting patients to discuss specific program goals.

• Collaborate with leadership, practice management, IT, and other stakeholders to collect and process data to improve the quality of clinical care.
• Produce and distribute chase list reports to clinical and patient-facing teams to guide patient care and improve care quality and performance.
• Review electronic medical records to confirm if patients are missing services or are navigating a transition in their care.
• Support quality improvement projects in Population Health and Ambulatory Care services, and take responsibility for agreed actions.
• Contribute to presentations, diagrams, and flowcharts for clinical staff.
• Implement population health programs as assigned, including, but not limited to:
  • The Prescription Helper program, sending targeted text message reminders and phone calls to patients who are overdue for refills, and providing assistance to patients enrolled for enhanced support.
  • The Recertification program, sending targeted text message reminders and phone calls to patients who need to renew their Medicaid coverage.
  • The Pathfinder program, providing direct care transitions support and treatment linkage to patients with mental health or substance use issues.
  • Perform other duties at the discretion of the Vice President.

This position will focus on the Pathfinder program, providing direct care transitions support and treatment linkage to patients with mental health or substance use issues visiting the SBH Emergency Department. The position holder will have an active role as part of the healthcare team and work one-on-one with patients to help them meet their goals. This includes engaging with patients, identifying barriers to treatment, managing a patient in crisis, and successfully connecting them with follow-up care.