<p>Summary:</p> <p>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 closely 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.</p> <p>Essential Duties and Responsibilities:</p> <ol> <li>Panel Ownership, Management & Risk Stratification </li></ol> <ul> <li>Maintain and actively manage assigned patient panels and prioritize patients using risk stratification </li><li>Prioritize outreach based on acuity, risk score, and care gaps </li><li>Continuously update patient status and engagement level </li><li>Uses population health management tools and reports </li><li>Owns an assigned panel of high-risk patients </li><li>Prioritizes outreach using risk stratification (RAF, utilization, gaps) </li><li>Maintains active tracking lists (EHR + external tools) </li><li>Responsible for measurable outcomes: </li><li>Care gap closure </li><li>Appointment completion </li><li>Reduced ER utilization </li></ul> <ol start="2"> <li>Clinical Integration & Point-of-Care Engagement (PCMH Critical) </li></ol> <ul> <li>Actively participate in daily clinical huddles by identifying care gaps for scheduled patients and recommending actions to close those gaps during the visit </li><li>Translate quality measures into actionable steps during visits </li><li>Serve as first-line resource for care gap questions from staff/providers </li><li>Engage patients during clinic visits, preferably after rooming and prior to the provider encounter. PHCs are expected to make every reasonable effort to see assigned patients during clinic visits. </li></ul> <ol start="3"> <li>Care Plan Development & Monitoring </li></ol> <ul> <li>Develop and maintain patient-centered SMART care plans with patient input </li><li>Document patient goals, barriers, and interventions </li><li>Monitor clinical indicators (A1c, BP, PHQ-9, etc.) </li><li>Provide the patient with a copy of the care plan during visits </li><li>Adjust care plans based on patient response. Document patient participation in care plan development </li></ul> <ol start="4"> <li>Outreach & Patient Engagement </li></ol> <ul> <li>Conduct structured outreach campaigns and panel-based engagement </li><li>Use motivational interviewing and culturally competent communication </li><li>Engage caregivers and family </li></ul> <ol start="5"> <li>Care Coordination </li></ol> <ul> <li>Coordinate transitions of care across outpatient, ED, inpatient, and community settings </li><li>Serve as liaison with: </li><li>Providers </li><li>Behavioral health </li><li>Community resources </li><li>External Case Management vendors </li><li>Oversees coordination and alignment with external case management vendors to avoid duplication and ensure continuity of care. </li><li>Acts as the primary point of coordination between internal care teams and external case management vendors </li></ul> <ol start="6"> <li>Documentation & Data Integrity </li></ol> <ul> <li>Ensure documentation supports clinical decision-making, care continuity, and audit readiness </li><li>Document all patient interactions in EHR </li><li>Maintain accurate care plans and Patient Case records </li><li>Track outreach attempts, outcomes, and barriers </li><li>Ensure data supports quality reporting and audits </li></ul> <ol start="7"> <li>Quality & Performance Contribution </li></ol> <ul> <li>Translate quality measures into patient-specific actions at the point of care </li><li>Support UDS, HEDIS, PCMH, and payer-driven quality initiatives </li><li>Close preventive and chronic care gaps </li><li>Participate in quality improvement activities with Director of Quality </li></ul> <ol start="8"> <li>Independence & Operational Authority </li></ol> <ul> <li>Works independently to manage assigned panel and prioritize work </li><li>Makes real-time decisions on outreach, engagement, and coordination </li><li>Escalates clinical concerns appropriately </li></ul> <p>Performance Expectations</p> <p>Performance is evaluated based on the following expectations:</p> <ul> <li>100% of assigned patients have active care plans </li><li>=25% of panels reviewed/updated quarterly </li><li>Daily outreach targets (7-10 panel calls/day) </li><li>Scheduling conversion targets (~40%) </li><li>Participation in daily huddles </li><li>Documented patient interactions in EHR </li><li>Panel prioritization metrics </li><li>Transition follow-up metrics </li></ul> <p>Qualifications:</p> <ul> <li>Associate degree required or bachelor's degree preferred </li><li>Minimum of 1 year experience in an FQHC, community health, care coordination, or population health setting preferred </li><li>Understanding of population health and team-based care models preferred </li><li>Demonstrated ability to work effectively within a multidisciplinary, team-based care environment </li><li>Strong written and verbal communication skills, including the ability to communicate clearly with patients, providers, and external partners </li><li>Proficiency with Electronic Health Records (EHR) and standard office technology; ability to learn new systems quickly </li><li>Strong organizational skills with the ability to manage multiple priorities and patient panels independently </li><li>Understanding of patient engagement strategies, care coordination workflows, and basic population health concepts preferred </li><li>Ability to build rapport with patients and navigate sensitive conversations with professionalism and empathy </li><li>Knowledge of community resources and ability to connect patients to appropriate services </li><li>Experience working with diverse patient populations and sensitivity to cultural, linguistic, and socioeconomic factors </li><li>Bilingual skills (Urdu, Hindi, Spanish, or Bosnian) preferred </li><li>Commitment to continuous learning, quality improvement, and performance accountability </li><li>Reliable attendance and ability to maintain consistent presence during clinic operations </li><li>Compliance with organizational health and safety requirements, including TB, COVID, and influenza policies </li><li>Effectively supports patients with varying social, behavioral, and economic needs by using practical, patient-centered approaches to communication, care coordination, and resource navigation. </li></ul> <p>Job Type: Full-time</p> <p>Pay: $20.00 - $25.00 per hour</p> <p>Benefits:</p> <ul> <li>Dental insurance </li><li>Health insurance </li><li>Paid time off </li><li>Retirement plan </li><li>Vision insurance </li></ul> <p>Work Location: In person</p>