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Patient Outreach Coordinator PHO

Cape Cod Healthcare

Hyannis, MA
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Cape Cod Healthcare
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Job Details

Cape Cod Healthcare

Department: HCI Phys Health Org - PHO
Schedule: Full-time 40 Hours per week
Shift: Day Shift
Hours: 8a-4p Monday-Friday
Job Details:

Cape Cod Healthcare is the leading provider of healthcare services for residents and visitors of Cape Cod.  With more than 450 physicians, 4,700 employees, and 1,100 volunteers, Cape Cod Healthcare operates two-acute care hospitals, the Cape's leading provider of homecare and hospice services (VNA), a skilled nursing and rehabilitation facility (JML Care Center), an assisted living facility (Heritage at Falmouth), the Cape's only local laboratory service (CCHC Laboratory Services) and numerous health programs.  We are currently seeking a dedicated Patient Outreach Coordinator PHO to join our team at Cape Cod Healthcare.    


Cape Cod Healthcare offers competitive salaries, excellent benefits packages, tuition reimbursement, and generous paid time off.


Supports the Physician Hospital Organization (PHO) population health management efforts through comprehensive collaboration with physician practices. Provides on-site support for the physician practices to meet organizational quality and efficiency goals with strong focus on patient engagement and optimization of practice work flow. 



1.     Works collaboratively with the PHO clinical quality improvement team and physician practice staff to coordinate improvement efforts related to quality and efficiency performance.

2.     Works with assigned practices to increase performance in quality measures in risk contracts by directly engaging patients to comply with preventive screenings and appointments.

3.     Outreach to patients through phone calls and mailings to schedule necessary appointments with Primary Care practice

4.     Work with specialist practices or other entities to coordinate care and ensure patient follow up

5.     Facilitate communications with patients and payers to ensure accurate eligibility to minimize inaccurate patient panel alignment

6.     Implement workflows to create increased communication for minimizing gaps in care including, but not limited to, flagging risk patients and point of care s

7.     Prepare/update patient charts to incorporate identified gaps in care needing to be addressed at point of care

8.     Support medical record data review/collection for quality measure appeals and exclusions

9.     Identify opportunities for process improvement and implement workflows to enhance performance

10.  Collaborate with PHO Case Management to facilitate patient enrollment in Helping Hands program

11.  Implement process improvement initiatives to increase performance with patient experience

12.  Ability to act as change agent to facilitate practice transformation with a focus on key elements of Patient Centered Medical Home and necessary operational components of population health management.

13.  Provide close collaboration with PHO Clinical Operations team to identify and escalate any issues at the practice level in a timely manner

14.  Follows PHO policies and procedures

15.  Performs other duties as assigned. 


Consistently provides service excellence to all patients, family members, visitors, volunteers and co-workers in a manner that reflects Cape Cod Healthcare's commitment to CARES: compassion, accountability, respect, excellence and service.



  • Bachelors' degree or equivalent work experience.
  • 3-5 years of healthcare experience preferred.
  • Excellent verbal and written communication skills
  • Strong organizational and project management skills including development of project parameters, goals, and time lines and outcome measurement. 
  • Must be able to maintain confidentiality of information.
  • Proficiency in MS Office, Excel, Word, PowerPoint and relational databases, Access preferred.
  • Proficiency with CEHRT including but not limited to eClinicalWorks, athenaClinicals, allscripts and Sorian Clinicals preferred
  • Ability to function effectively within an ever-changing environment and to meet deadlines and reprioritize as necessary.
  • Ability to work both independently and within a team environment and a multi-dimensional environment.
  • Creative, flexible, self-motivated, professional must possess sound judgment ability to plan and initiate new activities consistent with achieving service excellence.
  • Requisite poise, judgment, and trustworthiness to represent CCHN PHO to internal and external groups.
  • Maintains information in a confidential manner according to policy.


HR Use Only:

Zip Code: 02601
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