Population Health Coordinator - Medical Focus

Overview

At Groups, the Population Health Coordinator will play a key role in our organization by supporting the delivery of high-quality care to select high-acuity member populations, as well as members in select transitional periods of their recovery journey. Each population health coordinator will be assigned to one of the following areas of focus and specialization: 

Medical Focus

• Pregnant and postpartum members
• Recently hospitalized members and/or those with complex medical care-coordination needs
• Members struggling with polysubstance use 
• Members at highest risk of precipitated withdrawal

Within their area of focus, the Population Health Coordinator supports quality care-delivery and quality improvement via a mixture of: registry review and data management; internal and external interdisciplinary collaboration and care coordination; documentation review and preparation; and direct member-facing care (group and individual). 

This role will play a key part in pioneering  innovative care delivery methods at Groups, with a strong foundation in the Collaborative Care Model. As a result, the person in this role must be flexible, confident in engaging with multiple disciplines across various regions, and comfortable navigating ambiguity. This position requires a passion for leading, supporting, and participating in pilot projects to drive continuous improvement in patient care. 

Salary: $75,000 - $90,000

Schedule: Monday - Friday 8am - 5pm EST 

Responsibilities

Essential Functions:

Reasonable accommodations may be made to enable individuals with disabilities to perform these essential functions.

• Data and Registry Management/Collaborative Care Model Support
• Maintain an accurate registry of members enrolled in dedicated special populations or other care pathways
• Use the registry to assess progress, track outcomes, and prioritize daily tasks for yourself and other members of the care team
• Facilitate registry reviews with other members of the care team (counselors, medical providers, consulting specialists, etc) 
• Participate in caseload consultation and communicate resulting treatment recommendations to the care team 
• Use the registry to assess the quality of care for the relevant populations and to propose population-level quality improvement initiatives
• Care Coordination
• Support the local care teams by performing and documenting internal and external care coordination tasks for the most complex members or scenarios within the area of focus
• Assist in training staff on how to practice within the Collaborative Care Model (registry review, asynchronous consultations, concise presentations etc)
• Direct Member Care 
• Support the individual needs of members on an assigned member caseload (i.e. a subset of the members within the area of focus) via telephonic and SMS outreach, and individual telemedicine encounters 
• Perform screenings, structured assessments, brief therapeutic interventions, care coordination with community providers, and other tasks as assigned for select members
• Provide member education about common co-occurring mental health, physical health,  and substance abuse disorders and the available treatment options. 
• In partnership with peer support and care navigation, provide transitional care support to select high acuity members as they begin their recovery journey at Groups, including participation in interdisciplinary meetings, orientation groups, care coordination, and 1:1 member support 
• Facilitate and document treatment plan changes for members with the clinical and medical providers
• Escalate any urgent/crisis situations to the appropriate clinical and/or medical leadership and support team members through necessary follow up and safety planning activities  
• Pilot Support and Project Management 
• Provide administrative, technical, and leadership support on pilot projects, as delegated by medical, clinical, and operational leaders
• Duties Specific to Medical Focus: 
• Support medication management as prescribed by medical providers, focusing on treatment adherence monitoring, side effects, and effectiveness of treatment 
• Assist in creating and delivering low barrier, literacy and culturally appropriate educational materials for members, providers and co-prescribers on a variety of addiction and primary care related medical topics 
• Assist in the review of medical data and the preparation of medical documentation to support efficient, top-of-license medical care of medical colleagues
• Support with medial related coordination of care

While this position may have a primary focus in one of the areas listed above (Medical, Mental Health, or Social Care), team members are expected to contribute across focus areas as needed to best support members and ensure comprehensive care.

Qualifications

Knowledge, Skills and Abilities:

• Strong understanding of care coordination and case management
• Knowledge of health care regulations and HIPAA compliance 
• Excellent communication skills with the ability to effectively manage communications across a large, dispersed team and represent the organization to external audiences  
• Proficient in facilitating clear and efficient communication across telehealth, virtual platforms, telephone, and in-person care settings
• Willingness to work both in and out of the office depending on need, acquire additional training, willingness to adjust schedule hours to accommodate member care early or in the evening within the usual work week hours 
• Exceptional ability to maintain focus, prioritize tasks effectively, adapt to rapid organizational changes 
• Problem-solving and decision making abilities to navigate complete care situations
• Capacity to build trust and rapport with diverse patient populations
• Proficiency with multiple EMR’s, Microsoft Office / Google Suite (spreadsheet proficiency required), and other computer-based documentation tools 
• Excellent organizational and documentation skills
• Ability to analyze data and outcomes
• Ability to use discretion and work independently under general supervision
• Ability to understand and adhere to the Professional Code of Conduct

Qualifications & Requirements:

• Registered Nurse (RN) or (Maine Only) Licensed Practical Nurse (LPN) who completes the SAMHSA required training for an X‑DEA license required 
• Bachelor's degree in Nursing preferred
• At least 5 years experience providing direct patient-care in addiction medicine or other related areas of behavioral health, at high-quality, reputable organizations

For all Population Health Coordinators:

• For remote roles, access to reliable internet and telephone services, specifically 50M download and 10M upload packages or higher as well as a strong WiFi signal from your remote work location
• Must meet pre-employment requirements and maintain all applicable state and job-related guidelines for background screening.  Depending on state-specific requirements, this may include fingerprinting, drug testing, health screening, CPR/Basic First Aid and license/credential verifications