Patient Engagement and Population Health Coordinator

One Community Health•Sacramento, CA

3d•Onsite

About The Position

The Patient Engagement & Population Health Coordinator advances the organization's population health strategy by proactively engaging patients to improve access to care, close preventive and chronic disease care gaps, and support value-based care initiatives. The Coordinator partners with Quality, Health Center Managers, providers, care teams, and health plans to identify patients needing services, remove barriers to care, schedule appointments, and improve organizational performance on HEDIS, UDS, Medicare Stars, Annual Wellness Visits (AWVs), RAF/HCC initiatives, preventive screenings, and future population health programs. This position is part of the newly established Patient Engagement & Population Health Department, currently housed within the Call Center Division.

Requirements

High School Diploma or GED required.
Two years of experience in an FQHC, medical practice, population health, care coordination, scheduling, patient outreach, quality improvement, managed care, or call center preferred.

Nice To Haves

Epic/OCHIN and value-based care experience
Associate's degree
Knowledge of HEDIS, UDS, Medicare Stars, AWVs, RAF/HCC, and population health principles.
Excellent communication, customer service, and motivational interviewing skills.
Strong organizational, analytical, and critical thinking abilities.
Ability to prioritize multiple campaigns and work collaboratively across departments.
Commitment to patient-centered care, innovation, and continuous improvement.
Fluency in written and spoken English.
Fluency in at least one other of the languages most frequently spoken by OCH patients, English and (Arabic, Dari, Farsi, Pashto, Spanish, Ukrainian, Russian).
Cultural humility, and familiarity with the cultural practices of one or more of OCH's patient sub-populations.
Ability to collaborate effectively across a broad spectrum of backgrounds and perspectives.
Candidates who demonstrate inclusive thinking and interpersonal awareness help strengthen our commitment to equitable and compassionate care for all.

Responsibilities

Coordinate outreach campaigns supporting HEDIS, UDS, Medicare Stars, AWVs, RAF/HCC, preventive screenings, immunizations, chronic disease management, Women's Health, Pediatric preventive care, and future value-based care initiatives.
Develop and execute targeted outreach campaigns based on organizational priorities and quality goals.
Monitor registries and worklists to improve care gap closure.
Help implement the annual Clinical Quality Improvement Plan.
Conduct outreach via telephone, patient portal, SMS/text campaigns, automated outreach platforms, US mail, and future AI-supported technologies.
Educate patients regarding recommended services and schedule appointments during outreach.
Conduct follow-up outreach to improve appointment completion and reduce missed opportunities.
Utilize best practices in customer service and utilize techniques such as motivational interviewing to build rapport with patients to promote accessing services and closing quality gaps.
Lead outreach and scheduling efforts for Medicare Annual Wellness Visits.
Coordinate preventive screening campaigns including breast, cervical, colorectal cancer screening and diabetes-related services.
Coordinate patient outreach and scheduling for the mobile mammography bus and other gap closure and community health events.
Maximize utilization of available appointments through proactive outreach and waitlist management.
Identify barriers to care including transportation, language, insurance, financial concerns, and social needs.
Connect patients to Care Management, Community Health Workers, Behavioral Health, Dental, Eligibility, Referral Coordination, Health Education, NEST (CPSP), the ECM program and other available resources using warm handoffs whenever appropriate/possible.
Partner with Health Center Managers and operational leaders to fill provider schedules, reduce appointment gaps, support same-day access, new provider ramp-up, and targeted access initiatives.
Utilize Epic/OCHIN, Azara, registries, dashboards, portal messaging, text campaigns, automation tools, and future AI-assisted engagement solutions.
Recommend workflow improvements and support implementation of new technologies.
Document all outreach accurately in the EHR following OCH policies and procedures.
Track outreach attempts, appointments scheduled, appointments kept, care gaps closed, campaign outcomes, and referrals.