Population Health Coordinator

At Groups, the Population Health Coordinator will play a key role in our organization by supporting the delivery of high-quality care to select high-acuity member populations, as well as members in select transitional periods of their recovery journey. Each population health coordinator will be assigned to one of the following areas of focus and specialization: 

• Medical Focus
  
  • Pregnant and postpartum members
  • Recently hospitalized members and/or those with complex medical care-coordination needs
  • Members struggling with polysubstance use 
  • Members at highest risk of precipitated withdrawal
  • Other special populations
    
• Mental Health Focus

  • Members with Serious Mental Illness

  • Members with suicidal or homicidal ideation

  • Members recently admitted to a higher level of care or who may need admission to a higher level of care for a MH diagnosis

  • Members with a recent overdose 

  • Other special populations

• Social Care Focus
  • Members who were recently incarcerated
  • Members experiencing housing insecurity or homelessness
  • Members who have significant gaps in HRSNs (Health Related Social Needs such as food insecurity, financial needs, social support, etc)
  • Members who have case management needs
  • Other special populations

Within their area of focus, the Population Health Coordinator supports quality care-delivery and quality improvement via a mixture of: registry review and data management; internal and external interdisciplinary collaboration and care coordination; documentation review and preparation; and direct member-facing care (group and individual). 

This role will play a key part in pioneering  innovative care delivery methods at Groups, with a strong foundation in the Collaborative Care Model. As a result, the person in this role must be flexible, confident in engaging  with multiple disciplines across various regions, and comfortable navigating ambiguity. This position requires a passion for leading, supporting, and participating in pilot projects to drive continuous improvement in patient care. 

Essential Functions:

Reasonable accommodations may be made to enable individuals with disabilities to perform these essential functions.

• Data and Registry Management/Collaborative Care Model Support
• Maintain an accurate registry of members enrolled in dedicated special populations or other care pathways
• Use the registry to assess progress, track outcomes, and prioritize daily tasks for yourself and other members of the care team
• Facilitate registry reviews with other members of the care team (counselors, medical providers, consulting specialists, etc) 
• Participate in caseload consultation and communicate resulting treatment recommendations to the care team 
• Use the registry to assess the quality of care for the relevant populations and to propose population-level quality improvement initiatives
• Care Coordination
• Support the local care teams by performing and documenting internal and external care coordination tasks for the most complex members or scenarios within the area of focus
• Assist in training staff on how to practice within the Collaborative Care Model (registry review, asynchronous consultations, concise presentations etc)
• Direct Member Care 
• Support the individual needs of members on an assigned member caseload (i.e. a subset of the members within the area of focus) via telephonic and SMS outreach, and individual telemedicine encounters 
• Perform screenings, structured assessments, brief therapeutic interventions, care coordination with community providers, and other tasks as assigned for select members
• Provide member education about common co-occurring mental health, physical health,  and substance abuse disorders and the available treatment options. 
• In partnership with peer support and care navigation, provide transitional care support to select high acuity members as they begin their recovery journey at Groups, including participation in interdisciplinary meetings, orientation groups, care coordination, and 1:1 member support 
• Facilitate and document treatment plan changes for members with the clinical and medical providers
• Escalate any urgent/crisis situations to the appropriate clinical and/or medical leadership and support team members through necessary follow up and safety planning activities  
• Pilot Support and Project Management 
• Provide administrative, technical, and leadership support on pilot projects, as delegated by medical, clinical, and operational leaders
• Duties Specific to Medical Focus: 
• Support medication management as prescribed by medical providers, focusing on treatment adherence monitoring, side effects, and effectiveness of treatment 
• Assist in creating and delivering low barrier, literacy and culturally appropriate educational materials for members, providers and co-prescribers on a variety of addiction and primary care related medical topics 
• Assist in the review of medical data and the preparation of medical documentation to support efficient, top-of-license medical care of medical colleagues
• Support with medial related coordination of care
• Duties Specific to Mental Health Focus:
• Support member referral to a higher level of care or for mental health diagnoses
• Support a member’s transition from a higher level of care for a mental health diagnosis into the Groups treatment model
• Assist members with symptom management through direct care, guidance for the care team, or through connection to appropriate external care
• Support members and care team members through crisis or high risk situations, ensuring appropriate next steps, including safety planning
• Duties Specific to Social Care Focus:
• Support regional Recovery Support Specialist (RSS) teams on intensive case management and peer support services for high risk members across special populations
• Manage escalations related to health-related social needs 
• Facilitate member referrals to higher levels of care from a case management perspective 
• External care coordination with external case management agencies as needed
• Supporting members directly with very complex social needs

While this position may have a primary focus in one of the areas listed above (Medical, Mental Health, or Social Care), team members are expected to contribute across focus areas as needed to best support members and ensure comprehensive care.

Knowledge, Skills and Abilities:

• Strong understanding of care coordination and case management
• Knowledge of health care regulations and HIPAA compliance 
• Excellent communication skills with the ability to effectively manage communications across a large, dispersed team and represent the organization to external audiences  
• Proficient in facilitating clear and efficient communication across telehealth, virtual platforms, telephone, and in-person care settings
• Willingness to work both in and out of the office depending on need, acquire additional training, willingness to adjust schedule hours to accommodate member care early or in the evening within the usual work week hours 
• Exceptional ability to maintain focus, prioritize tasks effectively, adapt to rapid organizational changes 
• Problem-solving and decision making abilities to navigate complete care situations
• Capacity to build trust and rapport with diverse patient populations
• Proficiency with multiple EMR’s, Microsoft Office / Google Suite (spreadsheet proficiency required), and other computer-based documentation tools 
• Excellent organizational and documentation skills
• Ability to analyze data and outcomes
• Ability to use discretion and work independently under general supervision
• Ability to understand and adhere to the Professional Code of Conduct

Qualifications & Requirements:

• Medical Focus only: 
  • Registered Nurse (RN) or (Maine Only) Licensed Practical Nurse (LPN) who completes the SAMHSA required training for an X‑DEA license required 
  • Bachelor's degree in Nursing preferred
  • At least 5 years experience providing direct patient-care in addiction medicine or other related areas of behavioral health, at high-quality, reputable organizations
• Mental Health Focus only:
  • Current licensed clinical social worker
  • At least 5 years experience providing direct care or supervision in mental health or integrated behavioral health organizations, serving vulnerable populations
• Health Related Social Focus only:
  • Current social worker, certified peer, certified community health worker 
  • At least 5 years experience providing direct care or supervision in case management, care management, social work, or peer services

For all Population Health Coordinators:

• For remote roles, access to reliable internet and telephone services, specifically 50M download and 10M upload packages or higher as well as a strong WiFi signal from your remote work location
• Must meet pre-employment requirements and maintain all applicable state and job-related guidelines for background screening.  Depending on state-specific requirements, this may include fingerprinting, drug testing, health screening, CPR/Basic First Aid and license/credential verifications