Population Health Specialist II

Key Responsibilities

• Serve as a liaison between patients, caregivers, interdisciplinary care teams, and

community-based organizations to support whole-person, value-based care.

• Conduct telephonic and in-person outreach to an assigned patient panel to:

o Schedule appointments
o Complete needs assessments
o Support closure of care gaps aligned with quality and population health
metrics

• Meet patients in clinic, facility, or home settings to identify and address social

determinants of health (SDOH) impacting health outcomes and utilization.

• Collaborate with care managers, social workers, and providers to develop and

implement patient-centered care plans.

• Build trusted relationships with patients to drive engagement, adherence, and

improved health outcomes.

• Assist patients in navigating healthcare and community systems, including:

o Coordination of specialty care
o Appointment support or accompaniment (as appropriate)
o Assistance with enrollment forms and benefits

• Connect patients to community resources (e.g., food, housing, transportation,

behavioral health) to reduce barriers and prevent avoidable utilization.

• Facilitate communication among patients, families, providers, and community

partners to ensure coordinated care.

• Document all patient interactions in the electronic medical record (EMR) in

accordance with organizational and regulatory standards.

• Participate in interdisciplinary team meetings, case conferences, and population

health initiatives.

• Support efforts to reduce emergency department visits, hospital admissions, and

readmissions through proactive outreach and engagement.

• Travel within the community to meet patients where they are.

Minimum Qualifications

• High School diploma or GED required
• Minimum of 1 year of experience in healthcare, community-based services, or

social services, or equivalent combination of education and experience

• Experience using electronic medical records (EMR)

Preferred Qualifications

• Bilingual skills preferred
• Certified Community Health Worker (CCHW) preferred
• Experience working in a value-based care and/or population health environment

Core Competencies

• Strong interpersonal and relationship-building skills
• Cultural humility and ability to work effectively with diverse populations
• Understanding of value-based care and population health principles
• Knowledge of community resources and social service systems
• Ability to identify and address barriers to care (SDOH)
• Effective care coordination and patient advocacy skills
• Strong organizational and documentation skills

Work Environment

• Hybrid role including field-based (home/community visits) and office/telephonic

work

• Regular local travel required