TRC 1000x200

TRC - Primary Care - Population Health Manager 2

880 E 2nd St, Jamestown, NY 14701, USA Req #3853
Monday, September 19, 2022
The Resource Center has been providing services to persons with disabilities in the Chautauqua County area since 1958. From our humble beginnings as a gathering of parents and concerned citizens who wanted to provide educational and training opportunities for persons with developmental and intellectual disabilities, The Resource Center has grown into a comprehensive agency providing services to thousands of persons with all types and levels of disabilities.

The Resource Center is the largest non-governmental employer in Chautauqua County with more than 1,300 employees on its payroll.

The mission of The Resource Center is to support individuals with disabilities and other challenges in achieving maximum independence, contributing to their community, experiencing lifelong growth, and enjoying quality of life.


RESPONSIBLE TO: Practice Manager


Responsible for assisting patients in achieving health outcomes, as well as the other determinants that influence these outcomes and the interventions that impact the patient’s health, with the ultimate goal of achieving the “triple aim” of healthcare —better health, better care, and lower costs. Focus on high-risk individuals, ensuring ordered testing is completed, appointments are scheduled according to HEDIS and disease-management measures, and that health expectations are met. These health expectations are set by the patient, provider and the insurer. At the same time, monitoring and addressing comprehensive prevention and chronic care needs of every patient. The goal is to keep all individuals as healthy as possible, minimizing expensive intervention, and maximizing insurance incentives.


Exemplary customer service skills, including the ability to effectively deal with a variety of individuals including patients, providers and other customers in a calm and professional manner; must demonstrate excellent telephone and verbal communication skills, as well as, effective interpersonal skills which promote cooperation and teamwork; Demonstrated ability to effectively utilize multiple Electronic Health Record Systems preferred, including but not limited to Anasazi, Allscripts, Dentrix, and Therap, in addition to computer software programs such as Microsoft Word, Excel and PowerPoint. Comprehensive knowledge of information gathering, processing and filing systems; working knowledge of medical records management and office administration protocols, as well as, working knowledge of basic accounting and billing principles; flexibility, reliability and ability to self-direct and self-initiate in order to meet deadlines. Must be detail-oriented and possess strong organizational and time management skills, including the ability to effectively manage multiple priorities in a competent manner. Typing ability sufficient to perform data entry. Physical condition or reasonable accommodation(s) commensurate with the demands of the job.


Trainee: High School Diploma or GED and a minimum of 30 academic credit hours towards completion of a college degree from an accredited collegiate institution, plus two (2) years of demonstrated office experience, a minimum of one (1) year of which was in a medical office, medical billing, or related capacity. Candidates who are bilingual in English and Spanish preferred. Credentialing and enrollment experience strongly preferred. Advancement to a Level I upon successful attainment of a college degree and three (3) years experience in one or more of the aforementioned capacities.

Level I:Associate’s Degree plus three (3) years of demonstrated office experience, a minimum of one (1) year of which was in a medical office, medical billing, or related capacity. Candidates who are bilingual in English and Spanish preferred. Credentialing and enrollment experience strongly preferred. Advancement to a Level II upon successful attainment of a Bachelor’s Degree.

Level II: Bachelor’s Degree plus one (1) year of demonstrated experience in a medical office, medical billing, or related capacity. Candidates who are bilingual in English and Spanish preferred. Credentialing and enrollment experience strongly preferred.


1.DEFINE THE POPULATION:Work with providers, insurers and demographics to identify patients whose behavior puts them at risk of poor outcomes or health concerns. These might include individuals who need reminders for preventive care or tests, are overdue for care or not meeting goals, have failed to receive follow-up care after being reminded, or who could benefit from discussion of risk reduction. Behavioral health providers may identify individuals who can benefit from a dedicated care coordinator or peer support.

2.IDENTIFFY GAPS IN CARE:Reduce the gaps in care to improve health outcomes, which will reduce the cost of health care. Coordinate with other departments internally as well as other community organizations as necessary to ensure that patient needs are met and service systems are not fragmented.

3.STRATIFY RISKS: Using key indicators generate reports from EHR to identify patients in need or under served. Stratify patient populations by, but not limited to geography, health status, resource use, and demographics. Use this data to engage and intervene with those populations identified as being at high risk for poor health outcomes and high costs based on any or all of these characteristics.

4.ENGAGE PATIENTS: Foster Patient self-management to manage their health. Engagement will include messaging through patient portal to educate Diagnosis specific invention, calling patients, and occasionally work in the community. Connect patients with resource in the community that could put patients on the path to wellness.

5.MANAGE CARE: Work as part of an interdisciplinary practice team that understands the totality of the patient’s health care needs, engage the patient in decision-making and self-care provides or makes referrals for the full range of health and social services the patient requires, and guides and follows the patient through the continuum of care and across the lifespan.

6.MEASURE OUTCOMES:Create reports to identify key indicators and track the outcomes of the groups being served to develop, stratify, deploy, and monitor data measure success. Use reports generated by the insurance companies to ensure population are being managed. Foster a quality working relationships with all the insurance carriers to ensure health metrics are met and information is shared with key internal departments as necessary. Track incentive payments to ensure TRC is capturing incentives that are available. Monitor, interpret, and summarize program progress and results using trackers, trending, metrics, etc. Ensure all reporting and accountability requirements are in line with funding requirements.



Not applicable

Revision Date: 07/30/2020, 4/19/21

Primary Care


Grade 12/13/14, Non-Exempt


CFR: 505

Population Health Manager




 Describes the historical and current conditions that are affecting health of TRC patients (e.g., racism, historical trauma, power dynamics, natural disasters, poverty, housing)

 Identifies relationships that are affecting health of TRC patients (e.g., relationships among hospitals, health departments, community health centers, primary care providers, schools, community-based organizations, and other types of organizations)

 Establishes relationships to improve health for TRC patients (e.g., with organizations serving the same population, insurance companies, policy makers, customers/clients, and others)

 Maintains relationships that improve health for TRC patients

 Creates opportunities for individuals and organizations to collaborate to improve health of TRC patients (e.g., coalition building, facilitating collaboration)

 Participates in partnerships to improve health of TRC patients

 Uses information in collaboration with TRC clinical staff for assessing patient health needs and developing, implementing, evaluating, and improving policies, programs, and services

Community Health Assessment

 Describes factors affecting the health of TRC patients (e.g., inequity, income, education, environment, demographic trends, legislation)

 Determines quantitative and qualitative data and information (e.g., vital statistics, electronic health records, transportation patterns, unemployment rates, community input, health equity impact assessments) needed for assessing the health of TRC patients.

 Applies ethical principles in accessing, collecting, analyzing, using, maintaining, and disseminating data and information

 Collects valid and reliable quantitative and qualitative data

 Analyzes quantitative and qualitative data

 Interprets quantitative and qualitative data

 Uses informatics and information technology in accessing, collecting, analyzing, using, maintaining, and disseminating data and information.

 Develops population health assessments using information about health status, factors influencing health, and assets and resources

Population Health Improvement Planning and Action

 Determines population health improvement priorities based on TRC patient demographics and emerging insurance and HEDIS recommendations.

 Makes evidence-informed decisions for policies, programs, and services (ie. Using HEDIS measures, and any other available community and population health information)

 Develops population health improvement strategies (e.g., using evidence-based interventions, addressing identified health disparities and inequities, identifying potential resources)

 Implements strategies for continuous quality improvement

 Develops partnerships that will increase use of evidence in developing, implementing, and improving population health policies, programs, and services (e.g., between healthcare, public health, businesses, and community-based organizations)

 Advocates for resources that improve health of TRC patients (e.g., using evidence to demonstrate the need for a program, communicating the impact of a service, addressing social determinants of health)

Health Equity and Cultural Awareness

 Incorporates ethical standards of practice into all interactions with individuals, organizations, and communities

 Communicates in writing and orally with linguistic and cultural proficiency (e.g., using age-appropriate materials, incorporating images, considering health literacy level)

 Supports diverse perspectives in developing, implementing, and evaluating policies, programs, and services that affect the health of a community

 Ensures the diversity of individuals and populations is addressed in policies, programs, and services that affect the health of a community


Performs other related duties and participates in projects as assigned


Staff Training site

Timekeeping & payroll

Badge Access – Cappa

Requires access to the following electronic health records:





Also requires access to various portals for insurance companies and certifying bodies including, but not limited to:








The Resource Center is an equal employment opportunity employer and will not discriminate on the basis of race, color, creed, religion, sex, sexual orientation, gender identity, national origin, age, marital status, citizenship status, military status, domestic violence status, predisposing genetic characteristics or genetic information, physical or mental disability, any other category protected by law, or any other non-job related characteristic. As needed, The Resource Center will provide reasonable accommodations for disabilities to employees and applicants whenever such accommodation would not create an undue hardship or a safety concern in the conduct of TRC’s operations.

Other details

  • Job Family TRC - Active - PFL/DBL Eligible
  • Pay Type Hourly
Location on Google Maps
  • 880 E 2nd St, Jamestown, NY 14701, USA