Population Health & Quality Analytics Coordinator Position Summary: Codman Square Health Center s mission is to be a resource for the physical, mental and social well-being of our community. The Health Center strives to deliver services that support the achievement of its mission, while creating a sustainable care model that adapts to the changing healthcare environment. Through continuous quality improvement, the Health Center strives to provide high quality services and maintain optimal patient safety. The Population Health & Quality Analytics Coordinator is a key member of the Patient Center Medical Home (PCMH) transformation team and is responsible for overseeing population health analytics and patient outreach to support the achievement of the health center s quality goals and quality contract requirements. The position is responsible for management of our population health analytics software, developing and producing patient registries, overseeing the quality outreach responsibilities of our patient navigators, and providing grant management and project management for assigned grants and performance improvement initiatives. The Coordinator will work across all departments and disciplines and must have strong analytical, data management, communication, and presentation skills. Responsibilities: 1.) Population Health Management Lead the identification of annual clinical quality priorities by developing annual crosswalk of all required reporting for Quality Contracts and other external reporting requirements and health center priority projects. o Contracts include, but are not limited to: AQC, MSSP, TMP, PCPR, ACO, 330 Grant o External reporting requirements include, but are not limited to: UDS, MU, QPP o Providing clinical quality priority data to CMO on a monthly basis Oversee analytics and management of Population Management Software (Azara, HDS, Acuere, Business Objects, Reporting Workbench etc.) o Includes data mapping, data validation, administrative roles Serve as primary analyst for population management and quality measurement Support data/ reporting for additional grants (ie: PWTF, BHOP, HRSA BPR, etc). Develop and manage Patient Registries o Including ensuring data integrity, usability, distribution and recommendations on use. Develop and manage quality scorecards for Providers and Clinical Teams o Including ensuring data integrity, usability, distribution and recommendations on use. Work with IT/ Analytics Department on reporting issues Represent the health center in managing reporting with OCHIN Epic, BHN, and Azara Track and manage improvements; share data with clinical leaders and staff
o Includes, but is not limited to Team-Based Care, Provider meeting, Clinical Leaders, PIC, 1 st /3 rd Fridays etc Providing documentation for Population Management sections PCMH application Assist Providers with additional populations health management and performance improvement projects o PAP project, FM and IM Resident reports/projects, FIT test coordination with BMC, Diabetes CME Projects Managing EPIC Health Maintenance o Coordinating work of transferring historical data from CPS to EPIC o Coordinating work of entering recent results into EPIC 2.) Quality Contract Oversight Develop project plans to achieve Quality Contract Clinical Quality requirements. Create tracking tools to achieve Clinical Quality Contract Measures for included patients and for other Clinical Requirements for Quality Contracts. Manage Meaningful Use analytics and reporting for 30+ Providers o Track improvement work to ensure providers meet MU targets o Run all attestation reports o Submit all applications (includes gathering supporting documents, identifying 90 day patient volume threshold number) o Coordinate with Trudy and MeHI on registering providers in MU system Manage annual MSSP chart abstraction/ reporting o Reviewing report, dividing charts to review, training team on how to properly chart abstract, reviewing and validating their work, consolidating charts and submit to MSSP Manage AQC Quality contract, all claims reporting o Tracking and reporting on all quality measures, weekly hospital discharges, monthly high frequency ED o Regular meetings with MSO/BACO staff to track progress Partner with relevant staff and clinical leaders to implement project plans. Identify and implement best practices based on PDSA cycles and outcomes. o Train Staff on implementation of project plansstaff training on Azara, HM, quality measure improvement projects, scorecards, pre-visit planning. EPIC tools, MU work etc. Create analytics-oriented, team-based strategy for patient lists, distribution schedule, and data collection for assessment o Creation and distribution of registries, registry schedule, recommended use Review patient data with care teams and develop strategies to support pre-visit planning, patient outreach activities and other patient care management interventions o Including training on tools in EPIC (i.e. appt notes, RWB reports, patient lists) Prevention and Wellness Trust Fund
o attend monthly meetings with BPHC and other coordinating partners (CHCs and CBOs) o provide project management support to Asthma Team o develop pediatric asthma registry, validate registry, track improvements in measures by utilizing registry o reporting quarterly data to BPHC o creating Asthma RN internal referral in EPIC, editing asthma note templates, presenting data at regular meetings (PIC, Pedi/FM meeting) 3.) Outreach to Patients Develop patient outreach methodology, including efficient work distribution, scripts, assessment tools, etc. for use by health center staff and volunteers Oversee outreach to patients to achieve Health Center and Quality Contract Clinical Quality Goals by Patient Navigators and Clinical Staff. Distribute and collect data to organize and assess programming Report to contracts for AQC/ BACO re: process measures for funds flow Educate Providers and care teams on Planned Care model, and assist with implementation at the team level Develop and incorporate QI measures to monitor the implementation of new or improved practices related to the management of patient registries and patient care management interventions Oversee data collection and analysis as it relates to process improvements as needed Track success using Planned Care Model over time Assist Patient-Centered Medical Home (PCMH) team with care team development through use of appropriate data and patient registries 4.) Management of Patient Navigator Program Development, implementation, and assessment of patient navigator (PN) program o Support development of job descriptions; coordinate hiring, interviewing, and onboarding of patient navigators o Develop and implement job trainings Develop PN workflows, best practices, and quality assignments Supervise Patient Navigators, including recruitment, hiring, onboarding, training, and coaching. Oversee content work for PNs; liaise with staff and leadership on roll out of program, workflow changes, etc. Facilitate weekly PN meeting, and one-on-one supervisions Supervise volunteers and interns (ex: HealthCorps, Codman Academy/ MLK interns, college interns and volunteers) o Onboard, train, validate work, etc. 5.) External Reporting and Management:
Ensure compliance with all external reporting requirements; ensure timely and accurate data submission; work with health center leaders as needed; report to health center leadership on compliance efforts o Reports include, but are not limited to: AQC, BACO, grants, MSSP, UDS, PCPR o UDS- providing project management/coordination, reporting on clinical measure tables 6 and 7 Develop new analytics and reporting with internal and external stakeholders as needed Ensure compliance with BACO fund distribution models Manage all implementation and upkeep with Azara Represent CSHC with BACO analytics needs, including data integration o Managing reports box.com Partner with Boston Health Net, other CHC, BMC, and BACO staff to identify best practices, ensure compliance with external requirements o BU CME o MLCHC As assigned, work on, and represent CSHC for grants; manage grant projects; interface with funders and grant partners Represent CSHC at PWTF monthly meetings, learning sessions, etc. 5.) Other duties as assigned o Setting up referrals report for BH, CCM, Nutrition, etc. o Point person in all reporting needs (i.e. nutrition, substance use, CDPP, DM nurse, etc.) o Creating UC RN schedule template o Point person for Excel o Grant writing- HRSA o Distribution of internal reports Appointment Status Report, Open Encounters Report, Rx Refills report o Managing one-off payor reports Qualifications and Skills: Bachelors of relevant degree, Master s degree preferred Minimum of 2 years of experience in health or health related field involving database management & patient outreach /navigation experience Proficient in database management, use of Electronic Medical Record and Excel Project management experience Highly motivated, mission-driven individual Excellent oral and written communication skills, especially with patient population Enjoys challenges and working with a diverse workforce
Codman serves a diverse population. Applicants who have a multicultural background and/or bilingual are encouraged to apply. We offer a generous benefits package including: A retirement employee-funded 403(b) plan Competitive Medical, and Dental Employer-paid Life, Accidental Death & Dismemberment and Long-Term Disability Insurance Generous Vacation, Holiday, Personal and Sick Time Benefits Flexible Spending Reimbursement Accounts (Health and Dependent Care) Educational Assistance and tuition reimbursement Programs Commuter Benefits Other benefits and perks! To Apply: Send resume and cover letter to codemp@codman.org. Job Code: PHQACoord/Web CSHC is an Equal Opportunity Employer, M/F/D/V encouraged to apply Visit Codman.org to view other opportunities