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Population Health Advocate-PCMH, Medical Assistant (FT) Greeneville, TN

Ensures the overall success of the Patient-Centered Medical Home (PCMH) by collaboratively working with patients, physicians, practice teams, and the health plan to integrate the key features of the medical home model and the health plan measures, as defined by health plan.  Serves in the Patient Centered Medical Home (PCMH) Practice Model and works collaboratively with care teams to provide a medical home environment and coordinate care across the health care continuum for identified patients within the physician office setting.  Advocate will engage the member to assess and improve the status of current medical, environmental, and social needs.  The focus of the Population Health Advocate is to promote whole person health support to the member with emphasis on establishment of routine contact with the primary care physician and facilitate other care opportunities. Position is an integral member of the health care team who works to ensure safety, best practice and high quality standards of care are maintained across the continuum of care.

Responsible for coordinating a wide range of self-management support and disease registry activities for the clinic's patient population based on the health plan requirements.  Success will be measured by the results for the process and outcome performance measures of the population of patients in the clinic reported by health plan and internal clinical quality solutions.   The Population Health Advocate enhances the partnership of the PCMH and Health Plan by facilitating patient engagement in appropriate programs and services offered through Health Plans to provide health care support.    


Behavior Standards:
*    Demonstrates professional, appropriate, effective and tactful written, verbal, and non-verbal communication with patient, families, medical staff, colleagues, vendors, and other departments throughout the continuum of care to promote continuity of care and services and enhance clinic image.
*    Demonstrates positive professional customer service being respectful of all patients, coworkers and providers, treating all with equality regardless of their sex, color, race, medical problem, sexual orientation, religion or socioeconomic status.
*    Demonstrates a positive attitude by smiling and being courteous to all patients, coworkers and providers, making every effort to be non-judgmental with comments and conversation.
*    Acknowledges patient's rights on confidentiality issues, maintains patient confidentiality at all times, and follows HIPAA guidelines and regulations.
*    Participates in orientation and staff development activities as requested.
*    Proactively acts as patient advocate, responding with empathy and respect to resolve patient concerns and recognizes opportunities for improvement through patient concerns.
*    Complies with dress code and strives to act professionally in words and actions at all times.
*    Participates effectively as a team member in the clinic being accountable, helpful and welcoming to co-workers, providers and patients.  
*    Proactively continues to educate self to provide quality care and improve professional skills.

Duties Specific to a Population Health Advocate:
*    Responsible for carrying out key functions related to the success of the PCMH program including member outreach, PCMH reporting, performance measurement, and acting as key liaison between practice and Health Plan.
*    Maintains disease registry data applicable to the program assuring data is kept updated and communicated to care teams on a needed basis.
*    Collaborates with the member regarding opportunities for optimizing care and ensuring follow up visits are completed.
*    Ensures timely access to care for our patient population which includes same day access by working with the clinic's schedules.
*    Assist avoidable ER usage by patient follow and ensuring knowledge of alternates such as same day access or urgent care facilities.
*    Monitor and ensure follow up care to hospital admitted patients to assist in prevention of readmissions.
*    Monitor Identified High Risk members to ensure regular primary care visits and open care opportunities are completed.  Increase patient monitoring and referral tracking for high risk patients.
*    Assist in pre-visit planning based on care opportunities by working with patient care teams.
*    Patient Outreach that would include Identifying patients not meeting goals based on managed care metrics assigned as part of integrated P4P or other type performance contractual models.  Managing patient needs using Population Health Management (PHM) Dashboard Reminders for Identified Practice Measures that are managed care driven metrics.
*    Creating patient, physician, and clinic level quality performance reports alongside any managed care reports.
*    Acknowledges patient's rights on confidentiality issues, maintains patient confidentiality at all times, and follows all HIPAA guidelines and  regulations
*    Further maintains Health Plan and PCMH HIPAA compliance related to member records, member interaction and system access
*    Assessing and working on the patient's readiness to change, the importance of change, and confidence in ability to change; helping the patient to identify and overcome barriers
*    Acting as a liaison with hospitalized patients and the clinic. Following up with patients by phone shortly after hospital and emergency room discharges.  
*    Proactively acts as patient advocate, responding to and working to resolve patient concerns
*    Providing a link to other referral resources within the community or within the managed care health plan structure.
*    Assesses clinic needs and then collaborates with Clinic Staff, PCMH and Clinical Committees on strategies to achieve individual clinic level goals such as quality and efficiency.
*    Actively participates/coordinates committees as needed/requested, i.e. Performance Improvement Teams.
*    Communicates and coordinates with the healthcare team in the development of tools for optimal patient outcomes and report findings.
*    Ability to quickly identify and prioritize member needs and provide structured and focused support and interventions
*    Reviews reports as generated by PCMH and Health Plan for improvement and appropriate care opportunities.

MSHA expects that every team member will role model Patient-Centered Care behaviors and be guided by MSHA's Values and the Principles of Patient-Centered Care. Every member of MSHA's leadership team is accountable for coaching and monitoring reporting team members to ensure that the standards and initiatives of Patient-Centered Care are a living reality in their work units / Departments.

It is vital that an individual in this position be capable of good communication skills. It is of the utmost importance that written communication is legible.

MSHA expects all team members to support the VOS initiative by demonstrating awareness of the VOS system and effectively applying it to his/her work.

Job duties of this position may require access to protected patient information (PHI). The team member will be accountable for appropriate use of the record and compliance with all confidentiality and security policy and procedures related to use, access, and disclosure of PHI.

The Population Health Advocate reports directly to the RN Patient Care Manager.

*    CMA preferred.
*    Must have five years in data management and/or data abstraction experience. Experience in care management, utilization review and/or quality preferred.
*    Excellent Computer Skills with Microsoft Office Suite and Electronic Health Records required preferably Allscripts Electronic Health Record
*    Previous Case /Disease Management experience preferred
*    Proficiency with Motivational Interviewing and/or other behavioral change techniques
*    Meets on a routine basis with the cross-functional Health Plan team to review outcomes and discuss improvements and opportunities.
Exceptional level of critical thinking, analytical and creative problem solving skills required
*    Exceptional level of independence, organization, and interpersonal skills required
*    Proficient with team-building processes and participation in cross-functional teams