Pop Health Advocate - Cma (Ft) Brmmc

SCOPE OF POSITION
The Population Health Advocate will ensure the overall success of the Patient-Centered Medical Home (PCMH) by collaboratively working with patients, physicians, practice teams, and the health plan to integrate the key features of the medical home model and the health plan measures, as defined by health plan. This individual will serve in the Patient Centered Medical Home (PCMH) Practice Model and works collaboratively with care teams to provide a medical home environment and coordinate care across the health care continuum for identified patients within the physician office setting. Advocate will engage the member to assess and improve the status of current medical, environmental, and social needs. The focus of the Population Health Advocate is to promote whole person health support to the member with emphasis on establishment of routine contact with the primary care physician and facilitate other care opportunities. Position is an integral member of the health care team who works to ensure safety, best practice and high quality standards of care are maintained across the continuum of care.

Responsible for coordinating a wide range of self-management support and disease registry activities for the clinic’s patient population based on the health plan requirements. Success will be measured by the results for the process and outcome performance measures of the population of patients in the clinic reported by health plan and internal clinical quality solutions. The Population Health Advocate enhances the partnership of the PCMH and Health Plan by facilitating patient engagement in appropriate programs and services offered through Health Plans to provide health care support.

The Advocate will be responsible for carrying out key functions related to the success of the PCMH program including member outreach, PCMH reporting, performance measurement, and acting as key liaison between practice and Health Plan. The Advocate will maintain disease registry data applicable to the program assuring data is kept updated and communicated to care teams on a needed basis. This individual will collaborate regarding opportunities for optimizing care and ensuring follow up visits are completed. The Advocate will ensure timely access to care for our patient population which includes same day access by working with the clinic’s schedules. The Advocate will assist avoidable ER usage by patient follow and ensuring knowledge of alternates such as same day access or urgent care facilities. The Advocate will monitor and ensure follow up care to hospital admitted patients to assist in prevention of readmissions. In addition, the Advocate will monitor Identified High Risk members to ensure regular primary care visits and open care opportunities are completed and increase patient monitoring and referral tracking for high risk patients. This individual will assist in pre-visit planning based on care opportunities by working with patient care teams. The Advocate will create patient, physician, and clinic level quality performance reports alongside any managed care reports. The Advocate will acknowledge patient’s rights on confidentiality issues, maintains patient confidentiality at all times, and follows all HIPAA guidelines and regulations, as well as maintain Health Plan and PCMH HIPAA compliance related to member records, member interaction and system access. The Advocate will assess and work on the patient’s readiness to change, the importance of change, and confidence in ability to change; helping the patient to identify and overcome barriers. Acting as a liaison, the Advocate will work with hospitalized patients and the clinic. Following up with patients by phone shortly after hospital and emergency room discharges. The Advocate acts as patient advocate, responding to, and working to resolve patient concerns. This individual will provide a link to other referral resources within the community or within the managed care health plan structure. The Advocate will assess clinic needs and then collaborates with Clinic Staff, PCMH and Clinical Committees on strategies to achieve individual clinic level goals such as quality and efficiency. In addition, this individual will actively participate and coordinate committees as needed. The Advocate will communicate and coordinate with the healthcare team in the development of tools for optimal patient outcomes and report findings. The Advocate will be able to quickly identify and prioritize member needs and provide structured and focused support and interventions.

REPORTING RELATIONSHIP
See Table of Organization.

EDUCATION AND EXPERIENCE
Five years data management or data abstraction experience. Experience in Care Management, Case Management, Utilization Review, Disease Management, or Quality preferred. Excellent computer skills with Microsoft Office suite and electronic health records required, preferrably Allscripts experience. Proficiency with Motivational Interviewing and behavioral change techniques. Proficient with team building processes and participation in cross-functional teams.
Valid and active CMA licensure in appropriate state preferred