Population Health Coordinator

Summary:

The Population Health Coordinator (PHC) is an embedded member of the clinical care team responsible for team-based care, proactive panel management and closure of clinical care gaps. The PHC operates at the point of care and between visits, translating quality measures into patient-specific actions. This role serves as a primary liaison between providers, patients, community resources, and external case management vendors to improve outcomes for high-risk populations. Works in close collaboration with the Director of Quality to operationalize care gap closure strategies and quality initiatives. Functions as a real-time extension of the Quality program within clinical operations .

Essential Duties and Responsibilities:

1. Panel Ownership, Management & Risk Stratification Maintain and actively manage assigned patient panels and prioritize patients using risk stratification Prioritize outreach based on acuity, risk score, and care gaps Continuously update patient status and engagement level Uses population health management tools and reports Owns an assigned panel of high-risk patients Prioritizes outreach using risk stratification (RAF, utilization, gaps) Maintains active tracking lists (EHR + external tools) Responsible for measurable outcomes: Care gap closure Appointment completion Reduced ER utilization 2. Clinical Integration & Point-of-Care Engagement (PCMH Critical) Actively participate in daily clinical huddles by identifying care gaps for scheduled patients and recommending actions to close those gaps during the visit Engage patients during clinic visits, preferably after rooming and prior to provider encounter. PHCs are expected to make every reasonable effort to see assigned patients during clinic visits. Translate quality measures into actionable steps during visits Serve as first-line resource for care gap questions from staff/providers 3. Care Plan Development & Monitoring Develop and maintain patient-centered SMART care plans with patient input Document patient goals, barriers, and interventions Monitor clinical indicators (A1c, BP, PHQ-9, etc.) Adjust care plans based on patient response. Document patient participation in care plan development Provide patient with a copy of the care plan during visits 4. Outreach & Patient Engagement Conduct structured outreach campaigns and panel-based engagement Use motivational interviewing and culturally competent communication Engage caregivers and family 5. Care Coordination Coordinate transitions of care across outpatient, ED, inpatient, and community settings Serve as liaison with: Providers Behavioral health Community resources External Case Management vendors Oversees coordination and alignment with external case management vendors to avoid duplication and ensure continuity of care. Acts as the primary point of coordination between internal care teams and external case management vendors 6. Documentation & Data Integrity Ensure documentation supports clinical decision-making, care continuity, and audit readiness Document all patient interactions in EHR Maintain accurate care plans and Patient Case records Track outreach attempts, outcomes, and barriers Ensure data supports quality reporting and audits 7. Quality & Performance Contribution Translate quality measures into patient-specific actions at the point of care Support UDS, HEDIS, PCMH, and payer-driven quality initiatives Close preventive and chronic care gaps Participate in quality improvement activities with Director of Quality 8. Independence & Operational Authority Works independently to manage assigned panel and prioritize work Escalates clinical concerns appropriately Makes real-time decisions on outreach, engagement, and coordination Performance Expectations Performance is evaluated based on the following expectations: 100% of assigned patients have active care plans ≥25% of panels reviewed/updated quarterly Daily outreach targets (7-10 panel calls/day) Scheduling conversion targets (~40%) Participation in daily huddles Documented patient interactions in EHR Panel prioritization metrics Transition follow-up metrics

Qualifications:

Associate degree required or bachelor's degree preferred Minimum of 1 year experience in an FQHC, community health, care coordination, or population health setting preferred Understanding of population health and team-based care models preferred Demonstrated ability to work effectively within a multidisciplinary, team-based care environment Strong written and verbal communication skills, including the ability to communicate clearly with patients, providers, and external partners Proficiency with Electronic Health Records (EHR) and standard office technology; ability to learn new systems quickly Strong organizational skills with the ability to manage multiple priorities and patient panels independently Understanding of patient engagement strategies, care coordination workflows, and basic population health concepts preferred Ability to build rapport with patients and navigate sensitive conversations with professionalism and empathy Knowledge of community resources and ability to connect patients to appropriate services Experience working with diverse patient populations and sensitivity to cultural, linguistic, and socioeconomic factors Bilingual skills (Urdu, Hindi, Spanish, or Bosnian) preferred Commitment to continuous learning, quality improvement, and performance accountability Reliable attendance and ability to maintain consistent presence during clinic operations Compliance with organizational health and safety requirements, including TB, COVID, and influenza policies Effectively supports patients with varying social, behavioral, and economic needs by using practical, patient-centered approaches to communication, care coordination, and resource navigation.

Job Type:

Full-time Pay:

$20.00 - $25.00 per hour

Benefits:

Dental insurance Health insurance Paid time off Retirement plan Vision insurance

Work Location:

In person