Family Practice

Population Health Specialist

As a member of the Population Health Service Organization (PHSO), the Population Health Specialist (PHS) will play a vital role in the redesign of integrated care for Sparrow Care Network (SCN). Set-up as a centralized team to support the embedded Registered Nurse Care Facilitators (RNCFs), the PHSs will provide needed support in assisting with proactive outreach to patients. Often serving as the initial point of contact, the PHSs will be tasked with coordinating low-to-moderate risk outreach in the form of Provider-Delivered Care Management (PDCM) or Emergency Department (ED)/Transitional Care Management (TCM) calls post-discharge, assisting with resources referrals as needed, and screening patients for additional needs.

This team will work remotely within the PHSO office, providing ongoing telephonic support for individuals needing episodic care management. It'll be essential that the PHSs possess a strong understanding of scheduling workflows, are comfortable communicating to all team members, and have a sense of adaptability working offsite and supporting multiple practices.

Essential Duties:

This job description is intended to cover the minimum essential duties assigned on a regular basis. Caregivers may be asked to perform additional duties as assigned by their leader. Leadership has the right to alter or modify the duties of the position.

• Works with the embedded RNCFs to understand their prioritization process and routine of designating patients that are appropriate for support
• Provides prompt outreach to the assigned patients, while thoroughly documenting the conversation for team updates
• Coordinates care with the RNCF for patients with complex or ongoing needs
• Problem solves with patients and their family members to maximize their ability to follow preventative, remedial and/or rehabilitative recommendations
• Develops and maintains an effective professional working relationship with all patients, families, Physicians, Advanced Practice Providers (APPs) and additional care team members
• Arranges chronic disease education and referrals as needed for patients and families
• Screens selected cases to identify needed services and interventions to deliver quality comprehensive care that addresses the patient's full range of health care needs
• Identifies issues, which may impact medical outcomes based on comprehensive assessments that may include the patient's medical condition, support systems, finances, living situation, housing, behavior cognition, function/abilities, and the patient's choice and/or preference
• Collaborates with other members of the Sparrow Health System (SHS) team to collect, analyze, and utilize data for quality and process improvement activities
• Works with office staff as part of an Interdisciplinary Team, develops and implements a plan which addresses problems and needs identified in the assessment and ensures continuity of care by:
• Assisting patient and family with access to appropriate resources and services based on a thorough knowledge of community resources and eligibility requirements
• Advocating on behalf of patients and their families with internal/external resources and payers for needed services, including negotiating with insurance companies for non-covered benefits
• Communicating with patients, families, members of the health care team and others in a professional, diplomatic and empathetic manner
• Providing clear, concise, timely written documentation on the patient's medical record and on departmental records
• Acts as the initial point of contact (POC) for the centralized team, as the group researches and implements new workflows to support the embedded Care Facilitators
• Supports the development of new policies/procedures to ensure documentation is in place for the remote work
• Pilots potential programming related to post-discharge follow-ups, Social Determinants of Health (SDOH), Employee Health outreach and other areas of opportunity utilizing a structured Plan, Do, Check, Act (PDCA) framework
• Attends mandatory department and SHS meetings or trainings