The Population Health Support Specialist will be responsible for the implementation, monitoring, and completion of population health and quality initiatives at ReGenesis Health Care (RHC), most notably in those areas pertaining to HEDIS and UDS measures. This position will be expected to provide direct patient outreach via in-person, telephonic, and electronic methods. This team member will work with clinicians and other staff to connect patients to essential preventative services and chronic disease management as needed.

Duties and Responsibilities:

• Provide front-line support for HEDIS gaps closures and other utilization initiatives. which include, but is not limited to:
  • Patient in-reach and outreach via phone calls, mailings, text, e-messaging, and face to-face visits
  • Data collection and entry
  
  

• Manage and Monitor lists of patients for gaps in care, ER utilization, interventions.
• Support disease management programs, including scheduling, data entry, report generation and distribution.
• Evaluate patient eligibility status with regards to Medicare and Medicaid managed care health plans, and health plan web portals.
• Research all aspects of patient electronic medical records to evaluate utilization of care and patient account information
• Efficiently schedule, reschedule or cancel patient appointments for designated outpatient services in the RHC central scheduling system as it relates to

RHC's HEDIS gaps and Value-based Care coordination initiatives.

• Assess patient need for outside case management and provide direct referrals for internal and external support, reporting discovery of to PH Nurse for

further investigation and problem resolve.

• Obtain accurate demographics when scheduling appointments related to RHC's care initiatives.
• Create and maintain reports for tracking metrics regarding success of project productivity.
• Establish and maintain open and professional demeanor, and communication with other departments, and physicians whose services could be impacted by RHC's care initiatives.
• Attend and participate in monthly and other required meetings with community partners and Managed Care Organizations.

Other duties as assigned.

• Assist in the provision of technical assistance and health education to the community as requested.
• Assist in identifying appropriate educational materials for active and future initiatives.
• Serve on center committees as assigned.

• Follow formal Population Health/Value-based Care Department policies.