Care Gap Specialist

Job Description

Job Description

DEPARTMENT: Medical SUPERVISOR: Population Health Administrator

POSITION: Care Gap Specialist STATUS: EXEMPT

Full time position; temporary

SUMMARY: The Care Gap Specialist performs outreach to strategically targeted populations to attempt to close care gaps and assist patients in staying up to date on preventive health care. The Care Gap Specialist performs outreach for patients who are overdue on various specified preventive health measures, such as cancer screenings, well visits, and other clinically significant care gaps. The Care Gap Specialist also encourages Pre-Exposure Prophylaxis (PrEP) for high risk HIV negative patients, and assists with medication adherence, follow-up labs, and appointments for those electing to take PrEP for HIV prevention.

This position is a 40hrs/week position funded by the Health Federation of Philadelphia and is grant-supported through July 31, 2026.

ESSENTIAL FUNCTIONS

Care Gap Outreach

• Performs outreach and assists in assigned care teams to complete care gaps for a given panel of patients, for measures such as cancer screening (including colon and breast cancer), well visits (pediatric and adult), blood pressure checks, and diabetes-related care.

  • The populations and care gaps may shift over time depending on clinical needs; these will be discussed by and with the supervisor and other medical department leaders.

• Places referrals as needed to Social Services, Behavioral Health, etc., as appropriate based on patient interactions.

• Follow the scheduling rules when scheduling patients for preventive care.

• Achieves targets for outreach as discussed with the supervisor. Collaborates with the supervisor to problem-solve if targets are not met.

Navigation for Abnormal Cancer Screening

• Will perform outreach to patients who have had an abnormal cancer screening (ex., FIT test, or mammogram), and ensure proper follow-up has occurred.

• Collaborate with others, whether internally (such as Social Services) or externally (including Health Federation Navigator), to connect patients to care.

PrEP Duties

• Performs rapid HIV testing on-site on assigned days. Discusses PrEP as an option for patients with HIV negative results.

• Schedules patients who call and are interested in PrEP for appointments with clinicians.

• Links HIV positive persons to care.

• Collaborates with prescribing clinicians for PrEP prescriptions.

• Tracks patients who are due/overdue for labs.

• Performs outreach to patients who are overdue for lab tests and orders labs/schedules appointments as per established standing orders and protocols.

• Makes referrals as needed to Social Services, Behavioral Health, etc., as appropriate based on patient interactions.

• Attends community events with partners to gain and share knowledge about best practices for prescribing PrEP.

Other

• Assists with answering calls from the phone centers for NPE day and as mutually agreed upon between the supervisor and the Phone Center Manager.

• Provide Christ-centered spiritual care through prayer, scripture, and connection to churches as appropriate

• Other duties as assigned.

• Self-directed and motivated.

• Ability to effectively provide clinical care to socially and medically complex patients in a variety of non-traditional settings

• Exceptional organizational and interpersonal skills, with attention to detail required.

• Strong written and oral communication skills are required.

• Competency in Google Suite, knowledge of databases, and data analysis are preferred.

• Ability to work collaboratively in a team and manage multiple priorities, utilize effective time management skills, and exercise sound administrative and clinical judgment.

• Ability to analyze systems and to develop creative solutions to problems.

• Demonstrated cultural humility, strong cross-cultural sensitivity, and experience required.

• Requires the ability to travel to multiple office locations.

• Ability to integrate Christ-centered spiritual care into practice

• Serves all patients in a Christ-like manner, with respect, humility, love, and self-control.

EDUCATION, KNOWLEDGE, SKILLS, AND QUALIFICATIONS:

• High school diploma or GED required.

• Fully proficient in both English and Spanish.

• Demonstrable maturity and professionalism in the workplace.

• Passion for the integration of Esperanza Health Center’s Christ-centered mission into patient care.

WORKING CONDITIONS

• Requires the ability to be on your feet or at a desk, working in a high-paced environment

• Requires repetitive typing and data entry at a computer.

• Requires the ability to climb stairs, walk on uneven sidewalks in neighborhoods, and lift 10-20 lbs.