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We are currently seeking high-energy, engaging leaders with a passion for population health to help transform healthcare in the southeast. As a Population Health Transformation Specialist, you will lead the transition to outcomes-based care across multiple clinics, serving as the primary partner for providers, managers, and staff at each location on all matters related to population health. This role involves frequent site visits to assigned practices to support providers in understanding and utilizing available population health tools and technology. Specifically, you will assist in the development and implementation of pathways that support providers and practices in transitioning to value-based care. You will drive department initiatives, track individual performance goals, and provide ongoing training and education on quality measures, accurate RAF reporting, and strategies for closing care gaps. As an integral member of each partner practice, you will collaborate with them to achieve population health priorities while staying up-to-date with regulatory standards and guidelines, including HEDIS and STARs.

Requirements

• Strong communication and relationship building skills.
• Serve as a liaison to practice directors and managers along with clinical staff to facilitate implementation of population health initiatives.
• Provide direct support for provider achievement in improved financial, process and clinical outcomes.
• Problem solve with the intent to achieve effective progression of implementing initiatives.
• Work with the team to identify and develop recommendations for improvements as needed.
• Assist with the development of proposals, updates and summaries of provider performance.
• Assist in the development and execution of work plans to drive improvement in capturing quality measures and properly set patient risk scores.
• Ability to communicate areas of concern, needed resources, or barriers to achieving goals.
• Assist with monitoring and developing pathways for success for any providers experiencing underperformance and communicate strategies developed by the pop-health department for improvement.
• Review and interpret summary data and performance reports for practices and clinicians.
• Meet project specific goals and timelines.
• Share best practices within the organization.

Minimum Qualifications:

• Demonstrated experience with: Value-Based Payor Programs (incl. understanding of HEDIS Coding); HEDIS, STARS ratings and other population health initiatives.
• Electronic Health Record (eHR) use and documentation. Allscripts/Veradigm experience preferred.
• Demonstrated experience training clinical staff on value-based programs and requirements
• Demonstrated experience with auditing documents for gap-closure requirements
• High-school graduate (Associates preferred)

At 90 days the Population Health Transformation Associated is expected to demonstrate a growing competency in the following areas aligned with the minimum requirements of the role:

• Understanding of Value-Based Payer Programs
• Working knowledge of SEMG Value-Based Care (VBC) programs.
• Understand core principles of HEDIS gap closure with CPT II coding and its role in quality performance.
• Be able to explain basic VBC concepts to clinical team members in a clear, practical manner.

Familiarity with HEDIS, STARS, and Population Health Initiatives

• Identify and track core HEDIS and STARS measures for assigned practice locations.
• Understand how these measures are used to drive care improvement and payer incentives.
• Demonstrate ability to assist in tracking performance metrics at the practice or provider level.

EHR Use and Documentation (Veradigm & eCW)

• Achieve proficiency in navigating and retrieving supporting documents for gap closure within the organization’s EHR system.
• Be able to communicate documentation best practices for closing care gaps and reporting on quality measures to clinical staff

Training and Communication Skills

• Begin co-facilitating training sessions with managers and clinical team.
• Build confidence in presenting VBC workflows and expectations to clinical staff.
• Effectively communicate feedback or guidance to providers related to VBC performance.

Audit and Compliance Support

• Learn and apply standard audit processes for documentation and care gap closure.
• Accurately review charts and flag discrepancies or missed opportunities.
• Collaborate with peers or leads to report findings and support corrective action plans.

Key physical and mental requirements:

• 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

FLSA Classification: Non-exempt

Southeast Primary Care Partners is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability status, protected veteran status, or any other characteristic protected by law.

12/2024