Population Health Coordinator

Population Health Care Coordinator (Quality & Care Gap Specialist)


Location: Assigned Practice(s) / Remote or Hybrid, as Approved

The Population Health Care Coordinator (Quality & Care Gap Specialist) supports Southeast Medical Group's population health and value-based care initiatives by proactively identifying and addressing gaps in care, coordinating preventive services, facilitating patient outreach, and supporting transitions of care. Working collaboratively with primary care providers, clinical teams, Nurse Care Coordinators, and quality leadership, this position helps improve patient engagement, preventive care compliance, quality measure performance, and overall patient outcomes. The role is responsible for identifying patients requiring preventive screenings and Annual Wellness Visits (AWVs), conducting outreach and scheduling, obtaining and processing medical records, monitoring hospital and emergency department discharges, and maintaining accurate documentation to support quality reporting and care gap closure.

Requirements

Essential Duties & Responsibilities

1. Care Gap Identification & Closure

• - Review patient registries, EHR reports, and population health dashboards to identify outstanding preventive, chronic disease, and quality-related care gaps.
• - Conduct proactive patient outreach to facilitate appointments, screenings, and recommended preventive services.
• - Coordinate with practice teams to support timely completion of identified care needs.
• - Track outreach attempts, patient responses, scheduled services, and completed care gap activities.
• - Support quality improvement initiatives associated with Medicare, Accountable Care Organizations (ACOs), HEDIS, CMS, and other value-based care programs.
• - Assist with reconciling documented services and identifying opportunities to close gaps through appropriate clinical documentation.

2. Annual Wellness Visit (AWV) Coordination

• - Identify Medicare beneficiaries eligible or due for Annual Wellness Visits.
• - Contact patients to explain the purpose of AWVs and coordinate scheduling with their primary care practices.
• - Maintain accurate scheduling and completion records, including follow-up on canceled or missed appointments.
• - Collaborate with practice leadership to support AWV participation and completion goals.

3. Medical Records Management & Quality Documentation

• - Request and obtain external medical records from hospitals, specialists, laboratories, imaging facilities, and other healthcare organizations.
• - Review records for completeness and relevant preventive or chronic care documentation.
• - Accurately upload, index, and organize documents within the EHR according to established procedures.
• - Identify documentation supporting quality measure compliance and route information for appropriate review and validation.
• - Maintain accurate records and ensure compliance with HIPAA, patient confidentiality requirements, and organizational policies.

4. Transitions of Care Support

• - Monitor available hospital and emergency department admission, discharge, and transfer reports to identify patients requiring follow-up.
• - Notify the Nurse Care Coordinator or designated clinical team of patients requiring transitional care outreach or assessment.
• - Assist with scheduling post-discharge follow-up appointments and tracking appointment completion.
• - Document communication, referrals, and coordination activities in the appropriate system.
• - Promptly escalate identified clinical concerns to qualified clinical personnel.

5. Population Health Operations & Reporting

• - Maintain accurate patient outreach, scheduling, medical record, and care gap tracking information.
• - Assist with preparation and validation of population health reports and quality performance dashboards.
• - Monitor assigned work queues and follow up on outstanding activities to support timely resolution.
• - Partner with clinical operations, quality teams, and practice staff to improve workflows and patient engagement.
• - Identify recurring barriers to care gap closure and recommend opportunities for process improvement.
• - Participate in team meetings, training, and quality improvement initiatives.

Minimum Qualifications

Education & Certification

• - High school diploma or equivalent required.
• - Associate's or bachelor's degree in healthcare administration, public health, health sciences, or related field preferred.
• - Certified Medical Assistant (CMA/RMA) or similar healthcare certification preferred, but not required.

Experience

• - One or more years of experience in a medical office, healthcare administration, patient scheduling, care coordination, or related healthcare setting preferred.
• - Experience using Electronic Health Records (EHR) required or demonstrated ability to become proficient quickly.
• - Experience supporting population health, quality reporting, preventive care initiatives, or value-based care programs preferred.
• - Familiarity with Medicare Annual Wellness Visits, HEDIS/CMS measures, and transitional care workflows desirable.
• - Prior experience with patient outreach, medical records management, and healthcare data documentation preferred.

Knowledge, Skills & Abilities

• - Strong organizational skills with the ability to manage multiple patient work queues and competing priorities.
• - Excellent interpersonal, verbal, and written communication skills.
• - Strong customer service orientation and ability to engage patients professionally and compassionately.
• - Proficiency with EHR systems, Microsoft Office, and related healthcare technology.
• - Ability to accurately review, organize, and document patient information.
• - Understanding of preventive healthcare services, care gaps, and quality improvement processes.
• - Strong attention to detail, accuracy, and follow-through.
• - Ability to collaborate effectively with physicians, APPs, nursing, clinical support, and administrative personnel.
• - Ability to work independently while meeting established productivity and quality expectations.
• - Understanding of HIPAA requirements and confidentiality standards.

Key Performance Expectations

Performance may be evaluated through established departmental goals and measures, including:

• - Care Gap Closure: Timely outreach and coordination of assigned preventive and quality-related care gaps.
• - AWV Performance: Number of eligible patients contacted, visits scheduled, and completed appointments.
• - Patient Outreach: Timeliness, productivity, and documentation accuracy of patient engagement activities.
• - Medical Records: Timely retrieval, accurate indexing, and processing of external documentation.
• - Transitions of Care: Timely identification, notification, and coordination of post-discharge follow-up needs.
• - Data Quality: Accuracy and completeness of EHR documentation and assigned quality tracking activities.
• - Team Collaboration: Effective communication and support of practice and population health objectives.

Work Environment & Physical Requirements

• - Primarily office-based or approved remote/hybrid work utilizing a computer, telephone, and EHR systems.
• - Prolonged periods of sitting, computer use, and telephone communication.
• - Ability to perform essential job duties with or without reasonable accommodation.
• - Occasional travel to assigned practice locations or team meetings may be required.

Additional Expectations

• - Demonstrate commitment to Southeast Medical Group's mission of delivering high-quality, patient-centered primary care.
• - Maintain professionalism, confidentiality, accountability, and responsiveness in all interactions.
• - Comply with applicable federal and state regulations, organizational policies, and established patient care workflows.
• - Perform other related duties as assigned.

**Disclaimer:** This job description describes the general nature and level of work performed and is not intended to be an exhaustive list of responsibilities, qualifications, or requirements. Duties may change based on organizational and operational needs. This position is administrative and coordination-focused and does not independently perform clinical assessments, provide medical advice, or make treatment decisions.