Population Health Specialist

LifeLong Medical Care is looking for a Population Health Specialist to be based out of our Howard Daniel Clinic in Oakland. This position provides Primary Care Providers with dedicated panel management support by proactively identifying patient needs and monitoring and supporting patient follow-up. This is an entry-level position with a lot of opportunity to learn.

This is a full time, benefit eligible position, working 40 hours/week.

This position is represented by SEIU-UHW. Salaries and benefits are set by a collective bargaining agreement (CBA), and an employee in this position must remain a member in good standing of SEIU-UHW, as defined in the CBA.

LifeLong Medical Care is a large, multi-site, Federally Qualified Health Center (FQHC) with a rich history of providing innovative healthcare and social services to a wonderfully diverse patient community. Our patient-centered health home is a dynamic place to work, practice, and grow. We have over 15 primary care health centers and deliver integrated services including psychosocial, referrals, chronic disease management, dental, health education, home visits, and much, much more. LifeLong Medical Care is an equal opportunity employer. We strongly encourage applications from women, people of color, and bilingual and bicultural individuals and members of the lesbian, gay, bisexual, and transgender communities. Applicants shall not be discriminated against because of race, religion, sex, national origin, ethnicity, age, disability, political affiliation, sexual orientation, gender identity, color, marital status, or medical condition.

Benefits

Compensation: $20 - $21/hour. We offer excellent benefits including: medical, dental, vision (including dependent and domestic partner coverage), generous leave benefits including nine paid holidays, Flexible Spending Accounts, 403(b) retirement savings plan.

COVID-19 Vaccine Policy

In accordance with LifeLong Medical Care's commitment to provide and maintain a workplace that is free of known hazards, we have adopted a Mandatory COVID-19 Vaccine Policy to safeguard the health of our employees and their families; our patients and visitors; and the community at large from infectious diseases, that vaccinations may reduce. This policy will comply with all applicable laws and is based on guidance from the Centers for Disease Control and Order of the California State Public Health Officer. Unless a reasonable medical or religious accommodation is approved, all employees must receive COVID-19 vaccinations.

Drive quality assurance and quality improvement of the clinical quality measures, with support from Population Health Program Manager
• Maintain and share dashboard(s) of key processes and outcome measures for use in quality assurance and quality improvement of the clinical quality measures
• Using established protocols and systems, outreach to patients via phone and face-to-face interaction for chronic condition management or preventive care services, e.g., blood glucose test for diabetic patients, colorectal cancer screening, etc. and maintains documentation of contact with patients
• Oversee Social Determinants of Health (SDOH) improvement pilots - e.g., Veggie Give-Away, PRAPARE - and spread within health center, including consistent EHR documentation
• Actively participate and present data in key meetings, professional development, performance coaching, networking, and educational in-services
• Initiate and maintain patient Care Plans, including documentation, collaborating with other members of the patient care team, health coaching for key programs such as Blood Pressure at Home (BPAH)
• Educate, provide resources, and refer patients to additional care services and community services related to their health condition or social determinants
• Establish coordination of care and triage patient requests to Care Transitions panel
• Initiate case conferences with a member(s) of the patients' care team to address challenges
• Provide onboarding and ongoing training/coaching to other staff e.g., EHR documentation, etc.
• Perform other job-related duties as assigned

• Commitment to the provision of primary care services for the underserved with demonstrated ability and sensitivity in working with a variety of people from low-income populations with diverse educational, lifestyle, ethnic and cultural origins.
• Strong organizational, administrative, problem-solving skills, and ability to be flexible and adaptive to change.
• Effectively present information to other employees, community partners and vendors.
• Ability to work with individuals and organizations at the local level to build support.
• Ability to seek direction/approval on essential matters, yet work independently with little onsite supervision, using professional judgment and diplomacy.
• Work in a team-oriented environment with a number of professionals with different work styles and support needs.
• Excellent interpersonal, verbal, and written skills.
• Conduct oneself in internal and external settings in a way that reflects positively on LifeLong Medical Care as an organization of professional, confident, and sensitive staff.
• Ability to see how one's work intersects with that of other departments of LifeLong Medical Care and that of other partner organizations.
• Make appropriate use of knowledge/ expertise/ connections of other staff.
• Be creative and mature with a "can do", proactive attitude and an ability to continuously "scan" the environment, identifying and taking advantage of opportunities for improvement.

Job Requirements

• Equivalent combination of experience, skills and/or education.
• 0-1 year experience with essential duties or duties similar to the above.
• Experience retrieving, organizing, and assessing quantitative data.
• Proficient in Microsoft office suite

Job Preferences

• Experience working for a non-profit community health center or social service organization or related field.
• Electronic Health Records experience
• Working knowledge of community health problems including social and economic factors impacting health status.
• Experience and sensitivity working with low-income populations, substance users, and/or psychologically impaired persons.
• Experience in data analysis, health coaching, nutrition, adult education, group facilitation and/or patient outreach.