Population Health Analyst

Cornerstone Family Healthcare•Town of Cornwall, NY

1d•Onsite

About The Position

Cornerstone Family Healthcare is actively recruiting for a Population Health Analyst to join our growing team in Cornwall, NY. This role is responsible for coordinating and supporting population health and patient-centered medical home (PCMH) initiatives to continuously advance CFH’s quality of care and performance on quality measures. This role focuses on preventative outreach, pre-visit planning, data monitoring, chart review, and collaboration with care teams to ensure proactive member management, compliance with quality and PCMH standards, and achievement of incentive-based goals across payers and programs.

Requirements

High school diploma or GED
Bilingual Preferred
Highly organized with excellent oral and written communications skills
Minimum four years of experience in healthcare setting

Responsibilities

Act as a liaison with MCOs to evaluate data, perform preventative outreach, engage members, and coordinate care with internal CFH teams to meet incentive-based and quality goals.
Conduct preventative outreach and engagement, including reminder letters and follow-up phone calls, to schedule patients for overdue preventive and chronic care services.
Maintain tracking systems for outreach, reminders, and member engagement activities, ensuring timely follow-up throughout each month.
Utilize and support pre-visit planning tools, including training staff and care teams on effective use to improve visit readiness and quality outcomes.
Coordinate member management activities with care teams within the electronic clinical workflow, including documentation and task coordination in ECW.
Assist with PCMH workflows, care coordination processes, and team-based care initiatives, collaborating closely with care teams and leadership.
Monitor patient and provider compliance with quality, risk, and PCMH measures; report performance, gaps, and risks to care teams, the QI Coordinator, and the Director of Quality Improvement.
Perform chart reviews and support provider alerts to identify care gaps, risk factors, and opportunities for quality improvement.
Collaborate with QI providers to develop outreach and engagement plans for high-risk patients, including those with multiple chronic conditions or high utilization.
Review medical records and related documentation and provide feedback to support quality care delivery and measure accuracy.
Coordinate HEDIS and other quality chart reviews onsite or remotely with MCOs related to incentive and reporting programs.
Support scorecard development and reporting for all quality measures, including PCMH performance metrics.
Assist with data gathering, validation, and report preparation to meet MCO, CHIPA, UDS, PCMH, and internal reporting requirements.
Identify data discrepancies, validate data integrity, and submit help desk tickets as appropriate.
Assist in training staff on reporting platforms (e.g., Azara, ECW) and recommend additional training based on performance and data review.
Participate in CHIPA workgroup meetings and provide feedback to support workflow improvements and quality initiatives.
Attend and participate in monthly department, All Staff, leadership, and other required meetings.
Be familiar with and adhere to all clinical, administrative, and general policies and procedures as outlined in the Cornerstone Family Healthcare Policy and Procedure Manual and Employee Handbook.
Maintain confidentiality of all aspects of Cornerstone Family Healthcare including, but not limited to, patient confidentiality, financials, strategic initiatives, and employee relations.
Perform other related duties as assigned.