Population Health Outreach Specialist
- Minimum 2 years of patient-facing experience in clinical or care management setting
- Valid state licensure/certification as required
- Licensed Practical Nurse (LPN) or Registered Nurse (RN)
- All Level 1 requirements plus additional responsibility for device monitoring/management for remote patient monitoring
- Preferred: 3+ years of care management experience
- Conduct proactive outreach for Annual Wellness Visits for Medicare and Medicare Advantage patients
- Assess and enroll patients in care management programs (RPM, CCM, Pharmacy Outreach)
- Monitor and close care gaps for preventive screenings
- Support medication adherence initiatives with pharmacy team
- Coordinate care transitions from ER to community setting
- Navigate patients throughout value-based programs
- Document patient interactions and care coordination in EMR
- Track and report population health metrics and outcomes
- Manage remote patient monitoring devices and data
- Provide advanced care coordination for complex cases
- Mentor Level 1 specialists
- Lead quality improvement initiatives
- Strong proficiency in EMR systems
- Excellent verbal and written communication skills
- Proficient in Microsoft Office Suite
- Strong organizational and time management abilities
- Problem-solving and critical thinking skills
- Detail-oriented with strong documentation abilities
- Experience with population health management
- Knowledge of HEDIS/STARs measures
- Bilingual capabilities (English/Spanish)
- Ability to lift up to 50 pounds
- Ability to push or pull heavy objects using up to 50 pounds of force
- Ability to sit for extended periods of time
- Ability to stand for extended periods of time
- Ability to use fine motor skills to operate office equipment and/or machinery
- Ability to receive and comprehend instructions verbally and/or in writing
- Ability to use logical reasoning for simple and complex problem solving
- Ability to travel to multiple locations to support business needs as required
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