Population Health Specialist, Full Time, Days - Miami, United States - Jackson Health

Description

Department: Population Health

Address: Various Jackson Locations

Position Summary:

• The Population Health Specialist will work with medically complex individuals, many who may have one or more chronic disease conditions, and social barriers. He/she identifies the unmet needs of patients and assists them with accessing care, and links them to community services and resources.
• The Population Health specialist will support a primary care model of care, collaborate with the health care team across the health system and community, foster and engage patients in their own care and address social determinants of health.
• Through the gathering and review of medical data, and information provided by the patient, the Population Health Specialist develops and prioritizes the patients needs, sets mutually agreed upon goals with the patient and develops a service plan outlining interventions and target dates for achievement.

Duties & Responsibilities:

• Performs an initial case review of newly assigned patients, utilizing the electronic medical record to assess the patients medical history, including current medical problem list, medications, current plan of care and patient behaviors, in order to review the data and summarize the patients unmet needs for the planning of case management interventions.
• Works with identified patients to assess their health and social service needs and ensure linkage to Jackson Health System services and providers, and to community and state supported services and resources.
• Plans, develops, implements and maintains an individualized patient-specific Service Plan, prioritizing the patients needs. Include goals mutually agreed upon by the in order to ensure a patients engagement in his/her care and to foster patient motivation to improve his/her health behaviors and outcomes.
• Monitors and evaluates patient compliance with the Service Plan and the patients personal goals. Provides outpatient case management services which include assisting patients in gaining access to needed services including but not limited to nutritional support, housing, financial and insurance benefits, clothing, employment, transportation, medical/dental, social, vocational, and assessment of functional abilities and needs.
• Identifies gaps or barriers in access to care or services and intervene with solutions as possible. Identifies and initiates referrals and/or disseminate information to patients about available social services programs. Serves as a liaison for the patient with social service agencies. Fosters patient-centered health care team efforts to provide timely and coordinated care and services as expeditiously as possible.
• This includes participating and initiating in outbound/inbound calls/texts/emails with assigned patients and encouragement of continued and ongoing communication regarding all services. Advocates for patients as needed to ensure patient needs and choices are represented and supported by health care team members. Promotes healthy behaviors, coaching the patient and employing plan of care compliance strategies.
• Documents interactions with patients, and health care team members, and external agencies/resources contacted on behalf of patients. Complies with patient intervention and documentation protocols utilizing the electronic medical record and other computerized applications.
• Collaborates with the inpatient, behavioral health and Emergency Department health care team to gain knowledge of the discharge plan and patient follow-up care/appointments.
• Works closely with primary care providers and the health care team to provide services as needed and prescribed. Arranges and accompanies patients to clinical, community and financial assessment appointments as needed.
• Provides on-call access to patients after scheduled work hours by phone/email/text and record interactions in the electronic medical record or other computerized applications. Conducts home visits to assess social factors affecting the patient, as approved by the Program Director.
• Demonstrates behaviors of service excellence and CARE values (Compassion, Accountability, Respect and Expertise). Performs all other related job duties as assigned.

Experience:
Generally requires 3 to 5 years of related experience.

Education:
Bachelor's degree in related field is required

License Certification:
Valid license or certification is required as needed, based on the job or specialty.

Jackson Health System is an equal opportunity employer and makes employment decisions without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, veteran status, disability status, age, or any other status protected by law.