Population Health Specialist, North Carolina

We are actively recruiting a Population Health Specialist. The Population Health specialist is responsible for the implementation of our practice’s Population Health services program with diverse job functions designed to meet specific contractual and program-related requirements. This role focuses on improving the health status and care for individuals insured by Medicare, Medicare Advantage, Medicaid and commercial plans who are attributed to Aledade Accountable Care Organization (ACO) contracts.

Key Characteristics of the Successful Candidate:

• Strong understanding of value-based care principles, particularly as they relate to Population Health management and improvement
• A solution-oriented individual who can execute Population Health initiatives and deliver results
• Excellent communicator who can articulate the impact of Population Health initiatives within our practice and with our patients and their families/support system.
• Ability to use insights from clinical, quality, and cost data to inform Population Health initiatives
• Ability to work with diverse populations with a passion for eliminating health disparities

Duties and Responsibilities:

• Manages Population Health initiatives to support our practice’s success in providing value-based care for patients in our Aledade ACO contracts.
• Quarterbacks core Population Health initiatives, including: Daily huddle workflows for pre-visit planning, care gap closure, and resolution of suggested diagnoses; helping patients complete health risk assessments in preparation for Medicare AWVs;  managing outreach to patients on Aledade worklists (e.g., Wellness, Transitions of Care, Emergency Department follow-up, Care Gap closure, Uncontrolled Blood Pressure, Comprehensive Advance Care Planning). 
• Assists Aledade Product Team as a thought-partner for development of future iterations of the Aledade App based on practice observations and feedback.  
• Uses an evidence-based, data-driven approach to optimize Population Health outcomes.
• Mentors, coaches, and collaborates with key practice team members to execute Population Health strategies
• Assists in physician, advanced practice registered nurse (APRN, e.g., NP), physician assistant (PA), and office staff education regarding Population Health initiatives
• Identifies opportunities for continuous Population Health improvement, develops related plans of action, and implements process and documentation improvements
• Demonstrates commitment to providing outstanding customer service in a manner that is reflective of our mission, values, and customer service standards
• Maintains contact with the Aledade team and participates in collaborative learning opportunities.
• Performs related duties as assigned.

Requirements:

• Required: Clinical
• 3 or more years of direct patient care experience
• 1+ years of Population Health management experience
• Preferred: Clinical
• Recent experience in a Community Health Center or Primary Care Practice setting
• Comfortable working in a fast-paced environment and removing roadblocks and obstacles to achieve desired outcomes
• Strong written and verbal communication skills
• Adaptable, reliable, detail oriented and self-motivated 
• Ability to lead, coordinate, and facilitate Population Health initiatives

Who We Are:Aledade, a public benefit corporation, exists to empower the most transformational part of our health care landscape - independent primary care. We were founded in 2014, and since then, we've become the largest network of independent primary care in the country - helping practices, health centers and clinics deliver better care to their patients and thrive in value-based care. Additionally, by creating value-based contracts across a wide variety of payers, we aim to flip the script on the traditional fee-for-service model. Our work strengthens continuity of care, aligns incentives, and ensures primary care physicians are paid for what they do best - keeping patients healthy. If you want to help create a health care system that is good for patients, good for practices and good for society - and if you're eager to join a collaborative, inclusive and remote-first culture - you've come to the right place.
What Does This Mean for You?At Aledade, you will be part of a creative culture that is driven by a passion for tackling complex issues with respect, open-mindedness and a desire to learn. You will collaborate with team members who bring a wide range of experiences, interests, backgrounds, beliefs and achievements to their work - and who are all united by a shared passion for public health and a commitment to the Aledade mission.
In addition to time off to support work-life balance and enjoyment, we offer the following comprehensive benefits package designed f