Job Description

Under the general supervision of the Director of Program Quality and Development, this position coordinates initiatives aligned with the Chief Medical Officer’s strategies to enhance patient care, improve clinical outcomes, and strengthen our role as a community health leader. The Population Health Coordinator supports efforts to close care gaps, improve risk-adjusted outcomes, and implement evidence-based practices that align with value-based care models and population health priorities. This role collaborates across all levels of the organization to help design and execute quality improvement (QI) strategies, manage complex data reporting systems, and ensure compliance with payer and regulatory requirements. This person will assist the various clinical and operational teams with quality reporting and workflows that address preventive care, chronic disease management, and social determinants of health, while driving community engagement and fostering partnerships to improve access to care.

Requirements

Minimum qualifications:

Three years’ experience in a healthcare-related field pertaining to population health and quality improvement in a Federally Qualified Health Center (FQHC) environment or other type of Community Health Center. An equivalent combination of education and experience that provides the required knowledge, skills, and abilities may be qualifying.

Knowledge, Skills, and Abilities Required:

1. Working knowledge of the principles of continuous quality improvement, healthcare quality metrics, and reporting.

2. Working knowledge of UDS reporting.

3. Working knowledge of Medicare and HRSA Requirements

4. Working knowledge of and proficiency in the use of Windows-based PC systems and a range of software packages, including Microsoft Outlook, Word, Excel, Access, and PowerPoint.

5. Some knowledge of the concepts of Clinically Integrated Networks (CIN), Value-Based Care, and Accountable Care Organizations (ACO) in managed health care.

6. Ability to evaluate medical records and other healthcare data.

7. Ability to plan, organize, and lead data collection activities;

8. Ability to leverage, or willingness to learn, AI functionality in the strategic use of data

9. Ability to resolve simple and/or complex analytical problems.

10. Ability to present statistical and technical data clearly and understandably, utilizing appropriate visual aids.

11. Ability to effectively facilitate and coordinate the work of a workgroup engaged in quality improvement activities.

12. Ability to communicate effectively, both orally and in writing.

13. Ability to establish and maintain effective and cooperative working relationships with Heritage Health staff and others contacted during the course of work.

14. Ability to assume responsibility and exercise good judgment in making decisions within the scope of authority of the position.

15. Ability to think and work effectively under pressure and accurately complete tasks within established times.

16. Ability to prioritize tasks and deadlines.

17. Ability to maintain confidentiality.

Duties and Responsibilities:

1. Translating data insights into strategic population health and quality improvement priorities, informing organizational goals and cross-functional planning efforts, with duties including but not limited to

• Preparing custom reports to monitor clinical quality metrics and patient outcomes using EHR, Excel, and other Population Health Management applications.
• Conducting advanced data analysis to identify trends, track key performance indicators, and produce actionable insights.
• Developing and maintaining dashboards to support ongoing performance monitoring and driving continuous improvement for both internal and external stakeholders.
• Drafting annual and program-specific quality performance goal proposals by gathering and analyzing state and national benchmarks, value-based care targets, and internal historical performance trends to inform goal setting and monitor progress.

2. Leads the development, implementation, and tracking of population health action plans and quality improvement roadmaps across departments, with duties including but not limited to:

• Designing and implementing improvement strategies to address care gaps, chronic disease management, and preventive care measures.
• Preparing and delivering regular population health and quality performance updates to board members, executive leadership, governing committees, and payers to ensure alignment with strategic priorities.
• Leading interdisciplinary teams in quality improvement initiatives to enhance patient care and operational efficiency.
• Evaluating and refining clinical workflows to embed evidence-based practices and ensure compliance with regulatory requirements.

3. Driving the organization’s transition to value-based care models, with duties including but not limited to

• Optimizing performance in value-based contracts by overseeing the timely submission of quality, risk, membership, and performance data.
• Working with supplemental data sources such as immunization registries and lab vendors.
• Collaborating with clinical and operational leaders, including those from other health systems, on joint population health management initiatives.
• Monitoring performance against value-based program benchmarks and ensuring timely course correction through collaborative work with internal and external stakeholders.
• Analyzing risk adjustment and utilization data to support care coordination and maximize reimbursement opportunities.
• Acting as the primary liaison with payers participating in a value-based payment arrangement, ensuring contractual compliance, monitoring performance, and disseminating information to relevant internal stakeholders.

4. Promoting the implementation of standardized clinical quality workflows, with duties including but not limited to,

• Providing training and mentorship to staff on clinical quality measures, quality improvement principles, data analysis, and value-based care strategies.
• Fostering a culture of continuous learning and innovation among providers, care teams, and administrative staff.
• Creating and updating clinical quality workflows to ensure regulatory compliance and alignment with best practices.

5. Assisting in efforts to secure grants to support clinical quality and population health initiatives, with duties including but not limited to,

• Identifying potential funding opportunities and assisting with grant writing.
• Identifying, applying for, and implementing population health projects that enrich service delivery and patient care.
• Completing regular and required reporting for population health projects, ensuring objectives are met on time and within budget.
• Leading cross-functional teams in the planning and execution of grant-funded population health initiatives, ensuring measurable outcomes and sustainability.

6. Fostering community engagement and partnership to address health disparities, with duties including but not limited to,

• Representing Heritage Health at community gatherings, conferences, and events related to clinical quality and population health.
• Promoting efforts in addressing social drivers of health and improving patient population outcomes.
• Building and sustaining relationships with community partners to enhance care coordination and expand access to resources.

7. Heritage Health staff have an active role in our Patient Centered Medical Home model of care. This role is designated as part of the Heritage Health PCMH Care Team.

8. Performs miscellaneous job-related duties as assigned.