Population Health Coordinator

SPCP/Southeast Medical Group•North Charleston, SC

About The Position

The Population Health Care Coordinator (Quality & Care Gap Specialist) supports Southeast Medical Group’s population health and value-based care initiatives by identifying and addressing care gaps, coordinating preventive services, facilitating patient outreach, and supporting transitions of care. The coordinator works with primary care providers, clinical teams, Nurse Care Coordinators, and quality leadership to improve patient engagement, preventive care compliance, quality measure performance, and patient outcomes. The role identifies patients due for preventive screenings and Annual Wellness Visits (AWVs), conducts outreach and scheduling, obtains and processes medical records, monitors hospital and emergency department discharges, and maintains documentation for quality reporting and care gap closure. It is administrative and coordination-focused; it does not independently involve clinical assessments, medical advice, or treatment decisions. The position is primarily office-based or may be performed remotely or in a hybrid arrangement when approved. Occasional travel to assigned practices or team meetings may be required. Duties may change with organizational and operational needs.

Requirements

High school diploma or equivalent.
Experience using Electronic Health Records (EHR), or demonstrated ability to become proficient quickly.
Strong organizational skills and 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.
Ability to perform essential job duties with or without reasonable accommodation.

Nice To Haves

Associate’s or bachelor’s degree in healthcare administration, public health, health sciences, or a related field.
Certified Medical Assistant (CMA/RMA) or similar healthcare certification.
One or more years of experience in a medical office, healthcare administration, patient scheduling, care coordination, or a related healthcare setting.
Experience supporting population health, quality reporting, preventive care initiatives, or value-based care programs.
Familiarity with Medicare Annual Wellness Visits, HEDIS/CMS measures, and transitional care workflows.
Prior experience with patient outreach, medical records management, and healthcare data documentation.

Responsibilities

Review patient registries, EHR reports, and population health dashboards to identify outstanding preventive, chronic disease, and quality-related care gaps.
Contact patients to facilitate appointments, screenings, and recommended preventive services; coordinate with practice teams to complete identified care needs.
Track outreach attempts, patient responses, scheduled services, and completed care-gap activities.
Support quality improvement initiatives associated with Medicare, ACOs, HEDIS, CMS, and other value-based care programs; reconcile documented services and identify opportunities to close gaps through clinical documentation.
Identify Medicare beneficiaries eligible or due for Annual Wellness Visits, explain the purpose of AWVs, coordinate scheduling, and track cancellations, missed appointments, and completion.
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; upload, index, and organize documents in the EHR according to established procedures.
Identify documentation supporting quality measure compliance and route it for appropriate review and validation.
Maintain accurate records and comply with HIPAA, patient confidentiality requirements, and organizational policies.
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 completion; document communications, referrals, and coordination activities.
Promptly escalate identified clinical concerns to qualified clinical personnel.
Maintain accurate patient outreach, scheduling, medical record, and care-gap tracking information; assist with preparing and validating population health reports and quality 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 and recommend process improvements.
Participate in team meetings, training, and quality improvement initiatives.
Demonstrate professionalism, confidentiality, accountability, and responsiveness; comply with applicable regulations, organizational policies, and patient-care workflows.
Perform other related duties as assigned.