Job Description

JOB SUMMARY:
The Population Health Facilitator is responsible for analyzing and tracking the data for the Patient Centered Medical Home quality metrics. They actively participate as a team member and data resource in the medical homes across the Carle regional sites by working with EMR registries, dashboards, quality metrics and other data sources. They provide data for and assist the medical homes with proactive outreach to patients to address their health and wellness.

EDUCATIONAL REQUIREMENTS
Bachelor's Degree in Public Health, Population Health, Health Care Leadership or Related Field

CERTIFICATION & LICENSURE REQUIREMENTS
Valid Driver's License.

SKILLS AND KNOWLEDGE
Strong PC applications including Microsoft Word, Excel. Good interpersonal skills, communication (verbal and written), time management, and organizational skills. Detail oriented with demonstrated ability to handle multiple tasks/projects simultaneously and ensure value for each task/project. Must be able to function with a high degree of independence and as a member of the medical home team.


ESSENTIAL FUNCTIONS:

• Collects, analyzes and tracks data for population health management and actively participates as a team member and facilitator of the Patient-Centered Medical Homes.
• Provides data for, and assists the medical homes with proactive outreach to patients to address their health and wellness.
• Maintains current working knowledge of the NCQA PCMH Guidelines for PCMH transformation, recognition, and annual review procedures for Patient-Centered Medical Homes.
• PCMH quality metric oversight. Monthly review and analysis to maintain ongoing quality improvement and identify areas of need with regard to PCMH quality metrics at each location.
• Work closely with medical home leadership, physicians and care teams to ensure that the PCMH quality improvement goals are successful. This includes regular communication of the status of PCMH quality improvement projects using quality metrics data.
• Regional Involvement: Attend regional provider meetings to share and analyze data related to medical homes. Track and analyze data for multiple locations and a variety of practice areas such as Pediatrics, Family Medicine, Adult Medicine, and Geriatrics.
• Population Health Assessment: Assist Population Health and PCMH leadership in the evaluation and maintenance of each Medical Home across the region. Ongoing assessments conducted with leadership in each area will determine progress and sustainability of each medical home. Provide data for action plans and make recommendations with leadership in each area using PCMH methodology, identifying barriers and opportunities, as well as validating current state.
• Provide data to medical home leadership, physicians, and care teams for continued improvement with team-based care and practice organization, knowledge of the patient population, patient-centered access, care coordination, care management, and performance measurement.