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