Population Health Coordinator – Quality Improvement

Job Summary

Under the direction of the Director of Performance Improvement, the Population Health Coordinator will proactively manage health center populations with chronic conditions and those in need of preventative services to ensure the delivery of evidence-based care through a team-based, patient centered medical home approach. The Population Health Coordinator will address gaps in care through outreach to patients in need of routine screening and/or chronic disease management. The Population Health Coordinator will schedule appointments and/or enter outside data to close care gaps to improve patient care and achieve quality performance goals.


  • Bachelor’s Degree strongly preferred, may be substituted for years of relevant experience
  • Knowledge of Microsoft Excel required
  • Experience working in healthcare setting with patient-focused experience preferred
  • Experience in healthcare quality and population-based clinical quality initiatives preferred
  • Bilingual in Spanish or Albanian preferred

Representative Job Duties

Patient outreach and engagement

  • Utilizes the EHR and Azara DRVS to identify patients overdue for routine screening and chronic disease management.
  • Organizes and analyzes patient lists to prioritize outreach and data entry.
  • Performs chart review in the EHR prior to outreach to verify if a patient is due for screening.
  • Works collaboratively with health center providers and staff to address patient care.
  • Utilizes population health registries and the EHR to generate and deliver population health reminders (i.e., letters, telephone, patient portal messages, or text messages).
  • Makes calls to patients who need routine care, routine screening, or chronic disease management.
  • Verifies and updates demographic data in the Electronic Health Record (EHR).
  • Provides data entry support to the primary care teams.
  • Assists with patient care services such as education, referral coordination, and transportation.
  • Enrolls patients in the patient portal.
  • Communicates effectively, efficiently, and professionally over the phone with patients.


Performance Improvement

  • Reconciles patient charts to reports to verify data accuracy
  • Recognizes and reports data inconsistencies to the Clinical Quality Analyst in a timely manner.
  • Monitors progress on quality measures related to preventative screening and chronic disease management.
  • Improves patient care and data quality by entering external results in structured data fields in the EHR to record clinically relevant patient care performed outside of the health center.
  • Actively works to identify opportunities for improvement in workflows to improve population health and provides constructive ideas, suggestions, and feedback in a positive manner.
  • Coordinates with Clinical Quality Analyst and Director of Performance Improvement to promote quality throughout the health center and troubleshoot areas of concern.


Health Center Participation

  • Provides consistent, reliable and excellent customer service internally and externally.
  • Contributes to the team effort by supporting all staff members and maintaining an open and positive attitude.
  • Adheres to all health center and departmental policies and procedures.
  • Attends all required meetings.
  • Participates in additional quality assessment and improvement activities as requested.


Assumes other duties as requested


Skills and Abilities

  • Highly motivated and mission-driven
  • Highly organized and self-motivated individual with the ability work autonomously
  • Mature, professional, dependable
  • Ability to work independently as well as part of a team
  • Collaborative working style with the ability to work with staff across different departments, teams, and roles.
  • Ability to communicate effectively with diverse staff and patients
  • Warm and professional telephone manner
  • Excellent written communication skills
  • Excellent critical thinking skills
  • Skilled in use of other Microsoft Office applications including Word, PowerPoint, and Outlook
  • Superior organizational skills and follow-through
  • Ability to balance multiple projects, prioritize effectively, and follow up to complete tasks
  • Ability to learn HIPAA and adhere to data security best practices


Competitive benefits package.

Apply Now

Please submit cover letter and resume to hr@sbchc.org.

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