Population Health Advocate

Job description

Description Essential Duties and Responsibilities: - Reviews patient registries and other data sets to identify gaps in care, disease specific screenings, and basic preventative health screens. Communicates with patient and/or clinic staff, to ensure timely closure of identified gaps. - Documents activities/interventions within patient charts or other reporting formats, as appropriate. - Collects and tracks monthly, quarterly, and annual process improvement/quality measure data. - Conducts analysis of data in collaboration with a variety of care teams to assist in identification of improvement activities. Presents data collected in an organized format to facilitate analysis and identification of improvement opportunities. - Accesses daily reports to identify patients hospitalized, discharged, and treated in the Emergency Department (ED). Provides assistance with care coordination, facilitates communication between patients, caregivers, and providers, helps to addresses barriers to care, and promotes optimal allocation of resources. - Provides information to patients and families regarding community resources, medication assistance, and other healthcare needs. - Implement/assist wit...