Population Health Specialist

Thank you for your interest in career opportunities at Central City Concern!
Since 1979, the Portland Community has trusted Central City Concern (CCC) to help people create meaningful, long-term change. Every year, we serve more than 13,000 people experiencing, or at risk-of, homelessness with affordable and supportive housing, person-centered health care, addiction recovery and employment assistance. By providing health care, housing and jobs, CCC is ending homelessness in Portland and helping people achieve their highest potential.
CCC is Now Hiring a Full-Time Population Health Specialist to Join the Primary Care Team!
Schedule: Monday - Friday (8:00am - 4:30pm)
Location: Remote (Oregon-based)
POPULATION HEALTH SPECIALIST - ROLE SUMMARY: The Population Health Specialist is a key member of the Primary Care Service Line, responsible for identifying and coordinating care needs and gaps in care for patients attributed to Central City Concern’s Primary Care programs. This position will work in partnership with Primary Care leadership and care teams to support performance on quality metrics related to care gaps.
ESSENTIAL DUTIES AND RESPONSIBILITIES:
1. Identify patients with care gaps through use of reports, patient disease management registries, patient medical records, and other sources. Care gaps include but are not limited to:
a. Completion of routine preventive services;
b. Follow up for chronic disease management;
c. Follow up after no-shows to appointments;
d. Re-engagement of patients who have not had a recent appointment; and
e. Engagement of attributed patients who have yet established care.
2. Collaborate with Primary Care teams, other CCC service providers, and patient-identified supports to facilitate non-coercive care gap outreach to patients. Care gap outreach and facilitation includes but is not limited to:
a. Direct phone outreach to patients with care gaps;
b. Creation of job aids and standard work processes for clinic staff and volunteers performing outreach;
c. Training of clinic staff and volunteers performing outreach; and
d. Supervision of call banks for telephone outreach.
3. Support quality assurance and quality improvement related to closing care gaps, including familiarity with Clinical Quality Metrics and assessment of the impact of reporting those metrics:
a. Perform quality assurance reviews of records to verify quality of outreach and outreach documentation in the electronic health record and other tracking systems;
b. Train and coach care team staff to improve quality of outreach and outreach documentation;
c. Support process improvement projects related to care gaps;
d. Follow-up of hospital/ED discharges for pre-visit coordination, including problem and medications;
e. Provide routine reports to providers and care teams regarding hospital/ED status changes and performance on quality metrics related to care gaps; and
f. Identify quality metric data integrity issues and partner with Primary Care leadership and and IT teams to resolve.
4. Partner with Primary Care leadership and members of the Quality and IT teams to create and modify systems to manage outreach related to care gaps.
5. Obtain, process, and document health information related to care gaps. This may include securing medical records when appropriate, and documenting items in the EHR.
6. Maintain patient records as required by program standards and funding requirements.
7. Participate in training opportunities to advance skills and knowledge in physical health, addictions and mental health.
8. Work within scope of training and experience and seek consultation when appropriate.
9. Adhere to all state and federal privacy regulations, including HIPAA and 42 CFR Part 2, and to CCC policies and agreements regarding confidentiality, privacy, and security. Support compliance with all privacy and security requirements pursuant to community partners’ and outside providers’ patient confidentiality agreements, including privacy and security requirements for EMR access. This includes immediate reporting of any PHI breach of CCC or outside provider health records to the CCC Legal and Compliance departments, as well as to the program administrator.
DESCRIPTION OF OTHER DUTIES:
1. Perform other duties as assigned.
SKILLS AND ABILITIES:
1. Strong critical-thinking and problem-solving skills, with the ability to identify the root cause of issues and develop population-level solutions.
2. Ability to display a non-judgmental attitude and show diplomacy and tact, and work with a wide range of constituencies in a diverse community
3. Ability to work courteously and communicate effectively with patients, co-workers, program staff, and the public at large, including maintaining professional and appropriate interactions in stressful situations.
4. Ability to work as a team member and to establish priorities.
5. Ability to apply principles learned to new situations.
6. Ability to work independently, and to respond flexibly and positively to change.
7. Sufficient manual dexterity and physical ability to perform assigned tasks.
8. Ability to communicate clearly and concisely both orally and in writing.
9. Sound decision-making skills and excellent professional judgment, including ability to handle sensitive and confidential information on a daily and ongoing basis.
10. Ability to manage time and meet deadlines.
11. Ability to maintain accurate records (paper and electronic) and appropriately complete and route necessary paperwork.
12. Knowledge of de-escalation methods or ability to be trained in de-escalation methods.
MINIMUM QUALIFICATIONS:
1. Required: Associates Degree in a relevant field or Certified Medical Assistant.
*Preferred: Bachelor’s degree in a relevant field.
2. Required: Minimum one (1) year experience working in healthcare setting such as primary care settings or mental health clinic, preferably as a medical assistant or in a health education, care team support, or care coordination role.
3. Required: high level of computer literacy required, including the ability to learn new software applications.
*Preferred: experience with Electronic Health Records; experience with Microsoft Excel.
4. Preferred: one or more years’ experience working with homeless, low-income, or other vulnerable populations in a supportive role.
5. Preferred: Knowledge of health care systems, particularly knowledge of primary care, mental health, substance abuse, and/or community health care.
6. Have the competencies necessary to:
a. Communicate effectively orally and in writing;
b. Understand healthcare related terminology; and
c. provide outreach, engagement and supportive services.
7. Ability to adhere to Central City Concern’s drug-free workplace which encourages a safe, healthy and productive work environment and strictly complies with the Drug-Free Work Place Act of 1988. An employee shall not, in the workplace, unlawfully manufacture, distribute, dispense, possess or use a controlled substance or alcohol.
8. Must have current CPR certification or must be able to obtain in one month.
9. Must pass a pre-employment drug screen, TB test, and background check.
10. Sufficient manual dexterity and physical ability to perform duties.
11. Must adhere to agency’s non-discrimination policies.
12. Ability to effectively interact with co-workers and patients with diverse ethnic backgrounds, religious views, political affiliation, cultural backgrounds, life-styles and sexual orientations, and treat individuals with respect and dignity.
Central City Concern offers an incredible benefits package to our employees. We offer an extensive total rewards package to include base wages, medical, dental, vision and voluntary plans. Central City Concern also takes employees’ financial wellness into consideration and provides a rich retirement match. In the spirit of inclusivity, we celebrate 11 holidays and have a generous PTO (paid time off) plan.

• Generous paid time off plan which provides up to 4 weeks of PTO accrual in the first year. Accrual increases with longevity.
• Amazing 403(b) Retirement Savings plan with competitive employer match!
• 11 paid Holidays PLUS 2 Personal Holidays to be used at the employee’s discretion.
• Comprehensive Medical, Vision, and Dental insurance coverage.
• Employer Paid Life, Short Term Disability, AND Long Term Disability Insurance!

Central City Concern is a second chance employer and complies with applicable laws regarding consideration of criminal background for employment purposes. Government regulations, contractual requirements, or the duties of this particular job may require CCC to conduct a background check and take appropriate action to address prior criminal convictions.
Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities
The contractor will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with the contractor's legal duty to furnish information. 41 CFR 60-1.35(c)