Population Health Coordinator

Pay or shift range: $23.40 to $27.30 USD. The estimated range is the budgeted amount for this position. Final offers are based on various factors, including skill set, experience, location, qualifications and other job-related reasons. Description Established in 1980, the Greater Lawrence Family Health Center (GLFHC) is a multi-site mission-driven non-profit organization employing over 700 staff whose primary focus is providing the highest quality patient care to residents throughout the Merrimack Valley. Nationally recognized as a leader in community medicine (family practice, pediatrics, internal medicine, and geriatrics), GLFHC has clinical sites throughout the service area and is the sponsoring organization for the Lawrence Family Medicine Residency program. GLFHC is currently seeking a Population Health Coordinator (PHC) to join our care management team. The Population Health Coordinator (PHC) plays a key role in the health center’s overall quality, risk adjustment, team-based care, and Accountable Care Organization (ACO) performance. The PHC will support multiple PCMH teams and, under the direction of the PCMH team lead or delegate, will provide data coordination and outreach for patient populations with chronic illnesses and preventive health screenings. The PHC will support PCMH teams in organizing and optimizing pre-visit huddles, post‑care follow‑up, and proactive patient outreach as directed. This role will close care gaps by reviewing patient medical data and helping to schedule appointments and screenings that are overdue, and working with PCMH practice teams and clinician leadership. The PHC is an integral member of the Population Health program and helps support the integrated care team to promote optimal coordination of care for patients. The PHC builds relationships with patients to assist the primary care team in developing an effective and accessible plan of care and ultimately tracks adherence to this plan of care. Supports team-based pre‑visit planning activities and coordinates follow‑up and loop closure Under the leadership of the AVP of Clinical Integration and Director of Population Health, the PHC collaborates with Quality Improvement and ACO team members to help meet annual quality and risk adjustment goals Utilizes online data management systems such as the data warehouse and Arcadia to collaborate with the Data Analyst to create patient registries, validate patients’ empanelment to our health center, and identify/resolve patient quality and coding gaps Based on patient registries, tracks patients due for preventive care, chronic disease management, follow‑up of abnormal results, or other health care services to identify gaps in care Ensures timely and accurate documentation of outreach or other relevant information in the EHR Reviews registries of patient ED and hospital visits and coordinates with the nursing team to ensure appropriate follow‑up appointments are in place Communicates with care teams and other relevant staff to provide updates and obtain input on outreach, quality/coding initiatives as needed to help ensure quality and coding gaps are addressed Works closely with the ACO Performance Improvement team and other ACO and health center staff to monitor and optimize quality of care, clinical workflows, and accurate capturing of quality/coding data Qualifications Must have 3 years’ experience as a senior medical assistant and 5 years of experience in a clinical setting Bilingual (English / Spanish) required. Must be able to read and write English Demonstrable experience working in primary care practice support/quality management roles 1‑2 years of greater work experience in primary care, clinic, or population health role Experience working in managed care highly desirable Self‑motivated and self‑directed to work within a team and/or work independently Strong analytical, problem‑solving, planning and prioritization skills Excellent interpersonal skills required Excellent verbal and written communication skills required Basic working knowledge of Excel GLFHC offers a great working environment, comprehensive benefit package, growth opportunities and tuition reimbursement. Equal Opportunity Employer This employer is required to notify all applicants of their rights pursuant to federal employment laws. For further information, please review the Know Your Rights notice from the Department of Labor. #J-18808-Ljbffr Lawrence Partnership