Yale New Haven Health System


    Job Locations US-CT-Trumbull
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    Full Time Benefits Eligible
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  • Overview

    To be part of our organization, every employee should understand and share in the YNHHS Vision, support our Mission, and live our Values. These values—integrity, patient-centered, respect, accountability, and compassion—must guide what we do, as individuals and professionals, every day.

    The Health Tracker reports to the Manager of Care Coordination and works in collaboration with Care Coordinators, physicians, practice staff, EPIC Optimization staff, and other healthcare professionals. The Health Tracker?s focus is on using dashboards and other reporting to prospectively identify those patients in the practice who are behind on Health Maintenance or Diabetes Care and assist in closing those gaps. The Health Tracker shall demonstrate cultural competency with respect to populations served and will track patients through completion of all diagnostic plans to ensure timely receipt of care. The Health Tracker is responsible for coordinating a wide range of preventive care and disease management activities and running routine reports to facilitate tracking gaps in care. Works as a member of the patient care team and works closely with key collaborators across YNHHS and NEMG.



    • 1. Demonstrate and apply knowledge of the philosophy/principles of comprehensive, patient-centered, developmentally appropriate, and culturally sensitive patient care.
    • 2. Display sensitivity to and experience working with different cultures.
    • 3. Display comfort and interest working with patients around issues of healthcare access and adherence to clinical practice guidelines.
    • 4. Ability to provide input in assessing the needs of patients and participate in the development of comprehensive care plans.
    • 5. Generates and interprets reports from payors and routes to appropriate members of the health care team.
    • 6. Runs disease registries and identifies gaps in care prior to scheduled annual visits.
    • 7. In synergy with EMMI outreach campaigns, identifies and schedules patients due for preventive visits.
    • 8. Responsible for updating Health Maintenance including edit modifier under the instruction of MD.
    • 9. Completes all administrative functions associated with closing gaps in care in a timely manner.
    • 10. Assists the health care team in educating the patient on the importance of compliance with evidence-based guidelines.
    • 11. Assists patients with external resources as needed.
    • 12. Performs other duties as needed.



    High School Diploma.


    A minimum of 2 years of experience in healthcare as a Medical Assistant or Front Desk person.


    1. Possess ability to multi-task and work under time pressures.
    2. Demonstrate computer proficiency inclusive of ability to enter and access data/information.
    3. Demonstrate ability to be a self-starter and work independently.
    4. Core philosophy or values consistent with a patient-centered approach to care.
    5. Culturally effective capabilities demonstrating a sensitivity and responsiveness to varying cultural characteristics and beliefs.
    6. Demonstrates professional, appropriate, effective and tactful, written, verbal, and nonverbal communication with patients, families, medical staff, colleagues, vendors and other departments throughout the continuum of care to promote continuity of care and services and enhance practice image.
    7. Demonstrates positive professional customer service being respectful of all patients, coworkers and providers.
    8. Maintains patient confidentiality at all times.
    9. Participates effectively as a team member.
    10. Proactively acts as a patient advocate, responding with empathy and respect to resolve patient concerns and recognizes opportunities for improvement through patient concerns.
    11. Complies with dress code and strives to act professionally in words and actions at all times.
    12. Proactively continues to educate self to provide quality care and improve professional skills.
    13. Must be able to travel to various network locations.


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