Massachusetts Veterans Jobs

Job Type: Temporary

Time Type: Full time

Work Shift: Day (United States of America)

FLSA Status: Non-Exempt

When you join the growing BILH team, you're not just taking a job, you’re making a difference in people’s lives.

The Community Integrated Population Health Coordinator supports patients in achieving their healh care goals through innovative and patient-centered approaches. This role includes engaging patients, facilitating connections to community resources, and supporting care teams in addressing social determinants of health. Based on established workflows and strategies, the specialist will assist in driving practice improvement initiatives and enhancing care delivery. This hybrid role requires the ability to work on-site in primary care practices three days per week and independently manage a flexible schedule. This is a grant-funded position.

Job Description:

Essential Duties & Responsibilities including but not limited to:

Patient Engagement and Outreach:

· Perform direct outreach to engage patients, introduce clinic services, and schedule initial appointments with clinicians.

· Proactively contact patients to resolve and follow-up on potential barriers for appointment or program completion including reviewing patient completion of previous encounter “after visit summary” instructions to ensure completion prior to subsequent visit(s).

· Use motivational interviewing or similar techniques to support and encourage patients throughout their care journey.

· Identify and resolve barriers to appointment attendance or program participation, including reviewing and addressing incomplete “after visit summary” instructions.

· Contributes to the workflow and process improvements and the development of new ideas that impact the program with the BILHPN Performance Management team.

Resource Navigation:

· Utilize the community resource listing developed by the BILHPN team, which incorporates services offered by payors such as MassHealth ACO programs.

· Refer patients and caregivers to appropriate pre-identified resources and services addressing social determinants of health, such as housing, transportation, and food security.

· Ensure familiarity with these resources to provide accurate and efficient referrals, aligning with patient needs and care plans.

· Collaborate with care teams to seamlessly integrate resource navigation into patient care.

Documentation and Program Support: · Maintain accurate logs in relevant tools and platforms to ensure standardized documentation and consistent record maintenance. · Document all patient communications, ensuring compliance with organizational policies and program standards. · Review and analyze key performance indicators (KPIs) with team leaders to monitor program outcomes and identify opportunities for improvement. · Participate in workflow and process improvement initiatives, offering innovative ideas to enhance program efficiency and impact.

Education and Training:

· Conduct orientation and training sessions for staff, students, and medical professionals on resource navigation and available community partnerships, as needed.

Organizational Requirements:

Maintain strict adherence to all BILH and BILHPN Policies. Maintain courteous and effective interactions with colleagues and providers and stake holders. Demonstrate an understanding of the job description, performance expectations, and competency assessment. Demonstrate a commitment toward meeting and exceeding the needs of our customers and consistently adheres to customer service standards. Participate in departmental and/or interdepartmental quality improvement activities. Participate in and successfully completes Mandatory Education. Perform all other duties as needed or directed to meet the needs of the department.

Minimum Qualifications:

Education: · Education and Training: · Conduct orientation and training sessions for staff, students, and medical professionals on resource navigation and available community partnerships, as needed.

Licensure &

Certification: N/A

Experience: · Prior customer service or patient care experience preferred. · Experience working with diverse patient populations or in community-based settings is a plus.

Skills, Knowledge &

Abilities: · Multilingual candidates, fluent in Spanish or Creole. · Strong communication (oral and written), interpersonal, and organizational skills. · Ability to work collaboratively in a multicultural environment and as part of a multidisciplinary health care team. · Familiarity with Microsoft Office applications, including Outlook, Teams, SharePoint, and Excel. · Ability to handle multiple tasks and responsibilities effectively while maintaining confidentiality and sensitivity to cultural differences. · Basic understanding of medical terminology. · Flexibility to adapt to changing priorities and workflows. · Strong leadership and management skills. · Collaborative and team player. · Knowledge and understanding of value based care, risk contracts. · Understanding of process improvement tools and techniques. · Facility with Microsoft Word, Excel, Power Point. · Experience with Epic, Epic Healthy Planet and Arcadia preferred.

Key Relationships:

1 BILHPN Clinical Excellence Team

2 BILHPN Operations/Performance management teams

3 BILHPN Data Analytics team .

4 BILH Primary Care Leadership

5 PO and other LCU or employed practice leadership

6 BILHPN private practices and specialists

7 Hospital Leadership

Scope/Impact Statement:

Work Schedule: Indicate either Yes or No as appropriate. Hours of work may be subject to change based upon the needs of the business/department.

On Call: no Shift Rotation: no Weekends: no

As a health care organization, we have a responsibility to do everything in our power to care for and protect our patients, our colleagues and our communities. Beth Israel Lahey Health requires that all staff be vaccinated against influenza (flu) and COVID-19 as a condition of employment. Learn more (https://www.bilh.org/newsroom/bilh-to-require-covid-19-influenza-vaccines-for-all-clinicians-staff-by-oct-31) about this requirement.

More than 35,000 people working together. Nurses, doctors, technicians, therapists, researchers, teachers and more, making a difference in patients' lives. Your skill and compassion can make us even stronger.

Equal Opportunity Employer/Veterans/Disabled