Community Health Advocate Population Health

Asian Health Services · United States

• Under the direction of the Population Health Manager:

• • Identify patients who have been out of care and coordinate with Site Ops teams to inreach for appointments with PCP or medical team members

• • Identify patients who are due for Annual Wellness Visits and facilitate scheduling appointments

• • Identify care gaps and contact patients to complete outstanding orders as well as specialist office for notes documenting gap closure

• Operational support for Population Health Activity, including but not limited to reviewing Remote Patient Monitoring data and submit qualifying encounters to Billing.
• Administer Health Risk Assessments and SDOH screenings.
• Assist patients in troubleshooting device and connectivity challenges, while keeping them motivated to regularly use remote health devices and to improve health.
• Support patients in a variety of settings, including in-clinic, and in patient homes, either in person or using virtual visits (e.g. over phone or video calls, text messaging, emails.).
• Maintain expertise in frequently used technology for patient care, including video platforms, smartphones, and remote patient monitoring devices.
• Support program development and continuous improvement, such as developing educational materials (including handouts and videos), and improving policies and procedures, and contributing to data about program performance and patient experience.
• Document patient care activities in Electronic Health Record (EHR).
• Support care team in engaging and empowering patient to improve their health.
• Collaboration within AHS sites and entities outside of AHS.
• Represent AHS in community forums and meetings as needed.
• Provide clinic support as needed, including:
• • Schedule appointments; answer patient calls as needed.
  • Check-in and check-out.
  • Provide interpretation support.
  • Provide basic nutrition and health counseling.
• Other duties as assigned by the supervisor.

• Fosters an environment that promotes trust and cooperation among clients and staff.
• Enforces clinic policies and procedures, including maintenance of client confidentiality under HIPAA privacy rules, to ensure that the principles of AHS are implemented.
• Plays an active role in planning organization-wide activities such as AHS general membership meetings, fundraisers, special clinic days, and other events.
• Participates in general membership meetings, fundraisers, and other public events, as required.
• Participates in outreach activities, agency advocacy, and serves on ad hoc committees, as requested.
• Attends AHS staff retreats and Board of Directors meetings, as required.
• Participates in agency-wide quality improvement program processes and performance improvement teams to ensure excellence in the quality of services provided across the agency.

• The relationship between advocacy and improving the health of the Asian community.
• Cultural, socioeconomic and political factors affecting health in immigrant and refugee Asian communities.
• Health, social services, and community resources/leaders in at least one API community.
• Leading and working with diverse staff and community members respectfully and collaboratively.
• Innovative, cooperative, and collaborative problem-solving.
• Planning and coordinating small-medium scale projects and events.
• Strong interpersonal and communication skills bother oral and written.
• Organizing and engaging immigrant communities in education and advocacy activities.
• Proficiency in or ability to learn English and Asian language word processing.
• Ability to work under pressure and handle multiple tasks.
• Ability to exercise good judgment.
• Ability to work independently with minimal supervision.
• Available to work on weekends and evenings as needed.
• Decisions have a broad impact on a patient’s experience at AHS.
• High level of concentration required coordinating multiple program tasks, problem-solving with external organizations, and coordination with other departments and programs of the entire organization.

• A bachelor's degree and t wo years of work-related experience in a health setting -OR-
• A high school diploma and four years of relevant work experience
• Ability to speak, read, and write in a high proficiency level in an Asian language

• Preferred Bachelor’s degree majors: health, social service, or other closely related fields
• Preferred experience working in the community health field

Benefits That Support You
We're committed to supporting our team's well-being. Our comprehensive benefits package includes:

Health & Wellness

• 100% employer-paid medical, dental & vision coverage
• Acupuncture & chiropractic coverage

Time Off

• 12 vacation days
• 12 sick days
• 12 paid holidays + 3 floating holidays (additional flexible days you can use anytime)

Financial & Retirement

• 403(b) with 3% employer contribution + up to 2% match
• Flexible Spending Account (FSA) & Dependent Care Assistance

Additional Support

• Commuter benefits
• Long-Term Disability Insurance