Outreach Specialist, Population Health Services - Wyckoff Heights Medical Center : Job Details

The Outreach Specialist will collaborate with a team of Community Health Workers (CHWs) and together they will ensure coordination of care for patients inside and outside the hospital system, by conducting home and community visits and ongoing communication with patients at risk for being lost to follow up. . This role will also support ambulatory initiatives related to maintaining PCMH accreditation and implementing recommended or required best practices in care coordination and patient outreach and engagement. * Receive weekly reports from the Data Analysis team pertaining to patients that require interventions for targeted chronic conditions management or who are due for preventive interventions such as annual wellness visits, immunizations, and follow-up care after hospitalization *Ensure that patients targeted for closing gaps to care have appropriate and timely medical appointments and conduct patient outreach prior to and after appointments to ensure patients are engaged in their care and barriers to care are minimized. *Keep track of no-show appointments to perform outreach tasks including phone calls, texts, mailing certified letters and home visits, if required *Receive daily discharge reports from the House Officer and reach out and schedule patients that require follow up care post discharge *Work with the House Officer and Data team to identify patients that would benefit from more intensive care coordination within the department and ensure those patients are scheduled for Chronic Care Management appointments *Work with clinic-based health coaches to assist with tracking of SDoH deficiencies within the population and ensure that patients have adequate follow-up from the partnered Social Care Network (SCN) * Document in an accurate, comprehensive, and timely fashion the patient encounters, outreach attempts, and referrals for additional services and support. *Identify and communicate barriers to care within the Wyckoff system to patient engagement, timely access to care, and retention; such as scheduling challenges, miscommunication between different care teams and the patient, disconnects between clinicians' care goals and patient care goals, etc. *Assist with data gathering and reporting for assigned hospital initiatives (Community Impact Report, Special Projects & Grants) *Perform tasks essential to supporting Wyckoff's PCMH recertification and best practices for client outreach and engagement * Participate in regularly scheduled meetings, supervision, and trainings as requested by the direct supervisor or other hospital leaders * Bilingual English/Spanish highly preferred Educational Requirement: Bachelor's degree required. Experience: Required: Minimum 2 years of experience conducting community outreach and client engagement activities. Preferred: Experience conducting outreach events and activities related to health promotion, coordination of care, and outreach to communities of color. Equal Opportunity Employer This employer is required to notify all applicants of their rights pursuant to federal employment laws. For further information, please review the Know Your Rights notice from the Department of Labor.