Population Health Specialist II

Job Description Summary

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The Population Health Specialist (PHS) at CareMore Health plays a vital role in advancing a value-based care model focused on improving health outcomes, enhancing patient experience, and reducing the total cost of care. This role serves as a trusted liaison between patients, care teams, and community

resources. The PHS works to address social determinants of health (SDOH), remove barriers to care, and support patient engagement through outreach, education, and care coordination.

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How Will You Make An Impact & Requirements

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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:
• Schedule appointments
• Complete needs assessments
• 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:
• Coordination of specialty care
• Appointment support or accompaniment (as appropriate)
• 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
  
  

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Compensation

$21.00

to

$31.50