Quality - Quality and Population Health Coordinator

Quality & Population Health Coordinator

We are an FQHC community health center dedicated to embodying the values central to American Indian cultures. This includes respect for our patients, acknowledgement of the whole person, and a focus on working together to ensure health for the individual, and therefore the community. We invite persons of all tribes, ethnic backgrounds and walks of life to experience the comprehensive care we deliver and to contribute to the services we provide for children, youth, families, adults, and elders.

The Quality & Population Health Coordinator supports organizational quality improvement and population health initiatives through proactive patient outreach, care gap closure activities, referral follow-up, panel management support, and preventive care coordination.

This position works assigned outreach lists, supports patient engagement workflows, performs documentation and tracking activities, and assists with quality reporting processes related to HEDIS, GPRA, UDS, HRSA, managed care, value-based care, and grant-specific performance measures.

The role collaborates with clinical and operational teams to improve continuity of care, preventive service completion, chronic disease management outcomes, and patient retention while ensuring outreach activities are timely, accurate, and well-documented.

This position performs non-clinical outreach, engagement, scheduling support, and quality workflow coordination activities and does not provide clinical assessment, medical advice, or independent care management services.

Essential Duties and Responsibilities:

Patient Outreach, Engagement & Gap Closure

1. Coordinate and execute proactive outreach to patients to support follow-up care, re-engagement, closure of quality care gaps, and referral completion.
2. Prioritize and manage patient engagement worklists, including but not limited to: health plan identified care gaps, missed appointments, overdue preventive services, telehealth follow-ups, referral tracking/scheduling, and newly assigned patients.

Patient Outreach, Engagement & Gap Closure (continue)

1. Ensure timely and consistent follow-through on all assigned outreach activities, including tracking, resolution, and appropriate escalation of unresolved cases.
2. Serve as the primary point of accountability for assigned patient engagement workflows, ensuring alignment with quality improvement goals and performance measure targets.
3. Conduct targeted outreach campaigns focused on high-priority organizational quality measures, including but not limited to diabetes management, hypertension follow-up, colorectal cancer screening, cervical cancer screening, breast cancer screening, depression screening, behavioral health follow-up, immunizations, and chronic disease management initiatives.
4. Utilize payer gap reports, ECW registries, quality dashboards, assigned worklists, and population health tools to identify and prioritize patients requiring intervention for HEDIS, GPRA, HRSA, UDS, and value-based care measures.
5. Coordinate with providers, nursing staff, behavioral health, referral coordinators, and care teams to facilitate timely closure of identified care gaps and completion of preventive services.
6. Support panel management and patient retention initiatives through outreach to overdue, attributed, empaneled, high-risk, and medically complex patients.

Scheduling & Care Navigation

1. Coordinate appointment scheduling using ECW in accordance with provider templates, access protocols and efforts to close identified care gaps and support quality measure completion.
2. Guide patients through scheduling processes, setting expectations for preventive, follow-up, and referral-based services to support timely care delivery.
3. Support patients in understanding next steps in their care pathway, including preventive screenings, chronic care follow-up, and completion of recommended services
4. Identify, document, and escalate scheduling barriers or access constraints to leadership to support improved access and continuity of care

1. Coordinate scheduling efforts to maximize same-day care gap closure opportunities and completion of preventive services during patient visits.
2. Assist with pre-visit planning workflows to identify open care gaps, overdue screenings, referral needs, and chronic disease follow-up opportunities prior to scheduled appointments.

Documentation, Data Entry & Reporting

1. Accurately document all patient outreach attempts, communication outcomes, and coordination activities in in the Electronic Health Record (EHR).
2. Perform data entry and basic data validation to ensure accuracy, completeness, and integrity of quality and engagement data.
3. Track and maintain detailed outreach outcomes and external referrals, including follow-up to support completion, retrieval of supporting documentation, and appropriate care coordination to support performance monitoring and follow-up efforts.
4. Support medical record reviews and reporting activities to validate quality measure compliance and provide accurate data for operational review and performance monitoring accountability.
5. Support quality reporting validation activities related to HEDIS, GPRA, UDS, HRSA, managed care, and organizational performance measures.
6. Assist with obtaining and documenting external medical records, specialist reports, screening results, hospital documentation, and referral outcomes required for quality measure closure and reporting compliance.
7. Monitor assigned outreach and quality performance reports and escalate unresolved barriers impacting organizational quality goals.

Patient Experience Support

1. Promote a positive patient experience through respectful, culturally responsive communication.
2. Educate patients on SDCHC services and programs
3. Other duties as assigned based on department needs.

Performance Metrics and Accountability:

The Quality & Population Health Coordinator will be evaluated on the following key performance indicators to ensure high-quality service delivery and efficient patient access to care:

Category - Performance Metric - Standard / Expectation

Quality Performance - Assigned outreach completion rate - ≥ 95% monthly

Quality Performance - Care gap closure productivity - SDCHC established targets

Preventive Care - Improvement in preventive screening completion rates - Measured monthly/quarterly

Chronic Disease Management - Support improvement in diabetes, hypertension, and depression-related quality measures - SDCHC established targets

Patient Retention - Re-engagement of overdue/high-risk patients - Monthly tracking

Documentation Accuracy - Timely completion of outreach documentation - 100% same-day completion

Referral Follow-Up - Retrieval of external records and referral outcomes - Within established turnaround times

Panel Management - Completion of assigned quality outreach worklists - ≥ 95% monthly

Minimum Qualifications:

To successfully perform this job, the individual must be able to fulfill each essential duty and responsibility outlined in this position with performance standards. The qualifications listed below represent the necessary knowledge, skill and ability required.

1. High School Diploma or GED (equivalent).
2. 2-3 years related experience and/or training, or equivalent combination of education and experience.

Preferred:

1. Experience serving a multinational, multicultural population.
2. FQHC background.
3. Familiarity with Community Health Clinics and/or Indian Health Clinics.
4. ECW EHR.
5. Knowledge of HEDIS, GPRA, UDS, HRSA quality measures, value-based care initiatives, and population health workflows preferred.
6. Experience with care gap closure outreach, quality improvement initiatives, or population health programs preferred.
7. Familiarity with ECW registries, payer gap reports, quality dashboards, and preventive care outreach workflows preferred.

Special Conditions of Employment:

1. CPR/ BLS certification: Maintain a current Basic Life Support (BLS) certification issued by the American Heart Association (AHA), the American Red Cross, or an equivalent organization. Certification must include an in-person, hands-on skills assessment. Online-only certifications are not accepted.
2. Annual background checks: Consent to annual background checks as a condition of continued employment, to ensure compliance with organizational standards and eligibility requirements.
3. For-Cause Drug Screening: Comply with drug screening requirements when initiated by the organization for cause, to support a safe, compliant, and drug-free workplace.
4. Ongoing Compliance Requirements: Maintain up-to-date compliance with all required annual renewals, including professional licenses, certifications, physical examinations, TB testing, and mandatory regulatory trainings as assigned by the San Diego Community Health Center ( SDCHC ).

Knowledge, Skills, and Abilities:

1. Strong oral and written communication skills.
2. Exceptional time management skills
3. Highly organized and attention to detail.