What are the responsibilities and job description for the Population Health Coordinator position at United Community Health Center?
Description
The Population Health Coordinator supports the health center’s mission to improve quality, patient outcomes, and value-based performance by assisting with population health management activities. This role focuses on proactive outreach, care coordination, and data tracking for patients with chronic conditions, care gaps, or preventive care needs. The ideal candidate is a detail-oriented Medical Assistant with strong spreadsheet and data analytics skills who enjoys working with both patients and data to improve health outcomes.
Requirements
Essential Duties and Responsibilities
- Utilize population health tools, EMR dashboards (e.g., eCW, Azara), and spreadsheets to identify care gaps, track patient outcomes, and monitor quality metrics.
- Conduct patient outreach to schedule preventive and chronic care visits (e.g., AWVs, A1C testing, cancer screenings, immunizations).
- Collaborate with providers, care teams, and case managers to coordinate follow-up care and close care gaps.
- Assist with quality improvement initiatives, clinical quality measures, and other UDS measures.
- Support data collection, entry, and validation for payer programs, PCMH recognition, and value-based care initiatives.
- Create and maintain Excel trackers and dashboards to monitor progress toward clinical and operational goals.
- Prepare monthly and quarterly reports summarizing trends, patient outreach activities, and care gap closure rates.
- Work with the Quality team to analyze data and identify opportunities for performance improvement.
- Assist with provider education by compiling reports and examples of missed coding/documentation opportunities.
- Serve as a liaison between clinical teams and quality management for care coordination, workflow updates, and data accuracy.
- Maintain patient confidentiality and comply with all HIPAA, HRSA, and FQHC policies.
Qualifications
Education and Experience:
- High School Diploma or GED required.
- Certified or Registered Medical Assistant (CMA, RMA, CCMA) preferred.
- Minimum 2 years of experience in a primary care or FQHC setting.
- Experience with Excel (formulas, pivot tables, charts) and/or data reporting tools required.
- Experience using EMRs (eClinicalWorks preferred) and population health platforms such as Azara DRVS or similar systems.
Knowledge, Skills, and Abilities:
- Strong analytical and organizational skills with attention to detail.
- Ability to interpret clinical data and identify trends or opportunities.
- Effective communication and teamwork with both clinical and non-clinical staff.
- Comfortable making patient outreach calls and documenting outcomes.
- Knowledge of UDS, HEDIS, and Value-Based Care measures preferred.
Physical Requirements
- Ability to sit or stand for extended periods.
- Occasional lifting of up to 25lbs.
- Frequent use of computer, phone, and office equipment.
Working Conditions
- Office and clinical environment with potential for remote or hybrid work as assigned.
- Occasional travel between clinic sites may be required.
Salary : $21 - $27