Population Health Coordinator

Population Health Coordinator

The Population Health Coordinator supports patient care by helping manage outreach, preventive screenings, care gaps, patient metrics and registries, and EHR workflows. This position works with Medical, Patient Services, Quality Improvement, Health Information, and Informatics teams to ensure patients receive timely follow-up and to support performance goals related to HEDIS, GPRA, UDS, and other quality and compliance standards.

Essential Duties & Responsibilities

• Conduct outreach calls to patients to schedule appointments, preventive screenings, follow-up visits, and chronic care services.
• Manage working rosters and follow up on patients who need or miss appointments or are overdue for care.
• Identify, track, and help close care gaps, including missed screenings, overdue checkups, chronic disease follow-up, immunizations, and other preventive care needs.
• Maintain and update patient registries to ensure patients are being monitored and contacted in a timely manner.
• Support population health initiatives by reviewing patient data, generating patient lists, and helping care teams prioritize outreach.
• Assist with performance tracking for quality programs such as PPP, HEDIS, GPRA, UDS, and other required clinical quality measures.
• Collaborate with providers, care coordinators, Patient Services, and Quality Improvement staff to support value-based care and compliance targets.
• Act as an EHR super user by assisting staff with workflows, documentation processes, reporting tools, and basic troubleshooting.
• Support staff in using EHR tools related to care gaps, health maintenance, registries, dashboards, and quality reporting.
• Ensure patients receive appropriate follow-up and preventive services based on clinical guidelines and organizational priorities.
• Document outreach efforts, patient communication, scheduling outcomes, and follow-up needs accurately in the EHR.
• Help identify workflow barriers that prevent timely patient care and communicate concerns to the appropriate supervisor or team.
• Participate in quality improvement meetings, population health planning, and workflow improvement discussions as needed.
• Maintain patient confidentiality and follow all HIPAA, organizational, and compliance requirements.
• Monitor outcomes and collaborate with the Quality Improvement (QI) team to ensure program effectiveness and compliance with national standards, such as GPRA, UDS, and NCQA.
• Perform other duties as assigned.

Qualifications

• High school diploma or GED required.
• Associate or bachelor's degree in healthcare, public health, health information, medical assisting, or a related field preferred.
• Experience working in a healthcare, community health, FQHC, Tribal health, Urban Indian health, or medical office setting preferred.
• Experience using an Electronic Health Record system required; experience as an EHR super user preferred.
• Knowledge of preventive care, chronic disease management, care gaps, patient registries, and quality measures preferred.
• Familiarity with HEDIS, GPRA, UDS, NCQA, or value-based care programs preferred.
• Strong computer skills, including the ability to work with reports, spreadsheets, dashboards, and patient rosters.
• Strong communication skills and the ability to conduct professional and respectful patient outreach.
• Ability to work with clinical and non-clinical teams to support patient care and quality improvement goals.
• Strong attention to detail and ability to manage multiple patient lists, deadlines, and follow-up tasks.
• Ability to maintain confidentiality and handle sensitive patient information appropriately.
• Commitment to culturally responsive care and serving Native patients, families, and the broader community.

This position is primarily performed in a clinic or office setting. The role requires frequent computer use, telephone outreach, data review, EHR navigation, and communication with patients and staff. The position may require sitting for extended periods, occasional standing or walking throughout the clinic, and the ability to manage multiple priorities in a fast-paced healthcare environment.

Equal Employment Opportunity (EEO) Statement

The NATIVE Project is an equal-opportunity employer. We celebrate diversity and are committed to creating an inclusive environment for all employees.