Community Health Advocate – Population Health

Asian Health Services, founded in 1974, provides medical, dental, and behavioral health services to more than 50,000 patients. Our approach to well-being focuses on “whole patient health” for all. We go beyond our clinic walls and invest in our community’s overall health. We know that income, housing, and environmental struggles lie at the heart of poor health. That’s why we also address food insecurity, youth leadership, and culturally competent care while working towards supporting safer streets and vibrant communities.Job Summary: The Community Health Specialist in Population Health is responsible for the implementation of population health activities under the direct supervision of the Population Health Manager. The CHS identifies patients who are out of care or who have quality care gap closures and facilitates re-establishment of care with the Primary Care Provider or medical team members as well as the closure of quality gaps. This position will assist and educate patients and their families to improve engagement to improve their overall experience and their health outcomes.Essential Job FunctionsUnder 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 BillingAdminister Health Risk Assessments and SDOH screeningsAssist patients in troubleshooting device and connectivity challenges, while keeping them motivated to regularly use remote health devices and to improve healthSupport 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 devicesSupport 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 experienceDocument patient care activities in Electronic Health Record (EHR)Support care team in engaging and empowering patient to improve their healthCollaboration within AHS sites and entities outside of AHSRepresent AHS in community forums and meetings as neededProvide clinic support as needed, including:Schedule appointments; answer patient calls as neededCheck-in and check-outProvide interpretation supportProvide basic nutrition and health counselingOther duties as assigned by the supervisorGeneral Agency/AHS DutiesFosters an environment that promotes trust and cooperation among clients and staffEnforces clinic policies and procedures, including maintenance of client confidentiality under HIPAA privacy rules, to ensure that the principles of AHS are implementedPlays an active role in planning organization-wide activities such as AHS general membership meetings, fundraisers, special clinic days, and other eventsParticipates in general membership meetings, fundraisers, and other public events, as requiredParticipates in outreach activities, agency advocacy, and serves on ad hoc committees, as requestedAttends AHS staff retreats and Board of Directors meetings, as requiredParticipates in agency-wide quality improvement program processes and performance improvement teams to ensure excellence in the quality of services provided across the agency. Knowledge, Skills & AbilitiesThe relationship between advocacy and improving the health of the Asian communityCultural, socioeconomic and political factors affecting health in immigrant and refugee Asian communitiesHealth, social services, and community resources/leaders in at least one API communityLeading and working with diverse staff and community members respectfully and collaborativelyInnovative, cooperative, and collaborative problem-solvingPlanning and coordinating small-medium scale projects and eventsStrong interpersonal and communication skills bother oral and writtenOrganizing and engaging immigrant communities in education and advocacy activitiesProficiency in or ability to learn English and Asian language word processingAbility to work under pressure and handle multiple tasksAbility to exercise good judgmentAbility to work independently with minimal supervisionAvailable to work on weekends and evenings as neededDecisions have a broad impact on a patient’s experience at AHSHigh level of concentration required coordinating multiple program tasks, problem-solving with external organizations, and coordination with other departments and programs of the entire organization. Minimum QualificationsA bachelor's degree and two 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 QualificationsPreferred Bachelor’s degree majors: health, social service, or other closely related fields Preferred experience working in the community health field Benefits That Support YouWe're committed to supporting our team's well-being. Our comprehensive benefits package includes:Health & Wellness100% employer-paid medical, dental & vision coverageAcupuncture & chiropractic coverageTime Off12 vacation days12 sick days12 paid holidays + 3 floating holidays (additional flexible days you can use anytime)Financial & Retirement403(b) with 3% employer contribution + up to 2% matchFlexible Spending Account (FSA) & Dependent Care AssistanceAdditional SupportCommuter benefitsLong-Term Disability InsurancePlease note: We are not seeking support from staffing agencies at this time. Direct applicants only.We may use artificial intelligence (AI) tools to support parts of the hiring process, such as reviewing applications, analyzing resumes, or assessing responses and identifying potential inconsistencies or verification signals in application materials based on available information. These tools assist our recruitment team but do not replace human judgment. Final hiring decisions are ultimately made by humans. 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