Population Health Assistant

Position Summary

The Population Health Assistant supports Meridian HealthCare’s mission of providing integrated, whole-person care by advancing initiatives that improve clinical outcomes, reduce health disparities, and enhance care coordination across our Federally Qualified Health Center (FQHC) Look-Alike service lines. This position plays a key role in identifying and engaging at-risk patients, closing care gaps, and supporting value-based care performance through data analysis, quality improvement, and collaboration with interdisciplinary teams.

Key Responsibilities

• Utilize population health and EHR reporting tools to identify high-risk patients, monitor health outcomes, and track key quality metrics such as HEDIS, UDS, and other value-based indicators.
• Coordinate proactive outreach to patients for preventive care, chronic disease management, and follow-up after hospital or emergency department visits.
• Collaborate with primary care, behavioral health, case management, and recovery support teams to ensure coordinated, patient-centered care.
• Monitor and assist with Social Determinants of Health (SDOH) screenings, ensuring patients are connected with community resources and support services.
• Participate in quality improvement initiatives that strengthen clinical workflows, reduce care gaps, and align with HRSA and NCQA PCMH standards.
• Generate and analyze reports on clinical outcomes, patient engagement, and program effectiveness; assist with preparing data for HRSA and other grant or funding reports.
• Support implementation of care coordination protocols, chronic disease registries, and performance dashboards to improve population health outcomes.
• Conduct patient education and outreach to promote preventive health behaviors, treatment adherence, and participation in wellness programs.
• Provide training and technical assistance to staff regarding documentation, quality metrics, and care coordination workflows.
• Serve as a liaison between clinical teams and leadership to communicate trends, barriers, and opportunities for improvement.
  
  

Qualifications

Requirements

• Minimum of two years of experience in population health, care coordination, or quality improvement within an FQHC, primary care, or behavioral health setting.
• Knowledge of FQHC quality measures, UDS reporting, and value-based payment models.
• Familiarity with social determinants of health frameworks and resource referral systems.
• Proficiency in EHR systems (NextGen preferred), data dashboards, Microsoft Excel, and reporting tools.
• Strong analytical, organizational, and communication skills, with the ability to collaborate effectively across multiple disciplines.