Population Health Coordinator

The Family Practice & Counseling Services Network•Philadelphia, PA

17h•Hybrid

About The Position

The Population Health Coordinator is a hybrid community health, care coordination, and program implementation role responsible for supporting grant-funded programs, special initiatives, and priority Population Health activities across Family Practice & Counseling Services Network (FPCSN). Working under the direction of the Population Health Manager, the Coordinator initially supports implementation of the Title V Children and Youth with Special Health Care Needs (CYSHCN) Program and the FOCUS Grant, and may assume responsibility for additional grants, quality initiatives, outreach programs, community health projects, and other strategic Population Health initiatives as the department’s portfolio evolves. The Coordinator works directly with patients and families when appropriate, providing community health worker services, care coordination, resource navigation, outreach, health education, and assistance addressing social and logistical barriers to care. The position also supports Care Coordinators and interdisciplinary teams by helping carry out Population Health workflows approved by the Population Health Manager, supporting cross-site initiatives, providing program-specific information and materials, and assisting with short-term coverage or priority caseload needs as directed. This position is designed to bridge frontline community health work with program coordination and implementation. It does not directly supervise Care Coordinators unless formally assigned supervisory responsibility by FPCSN. The Coordinator serves as a programmatic resource and implementation partner to the Population Health Manager, Care Coordinators, clinical teams, community partners, and grant stakeholders.

Requirements

Associate degree in community health, health sciences, health administration, human services, social work, or a related field, or an equivalent combination of education and relevant experience, required.
Minimum of three (3) years of relevant experience in community health, care coordination, patient navigation, health or human services, program coordination, case management, or a related field, required.
Demonstrated experience coordinating multiple priorities, maintaining accurate documentation, and working independently across teams or sites, required.
Pennsylvania Certified Community Health Worker (CCHW) certification through the Pennsylvania Certification Board is required at time of hire where the incumbent will perform grant-funded or managed care community health worker functions requiring an immediately deployable certified community health worker. Where certification is not required at hire, the incumbent must obtain certification within six (6) months of hire and maintain it in good standing as a condition of continued employment.
Ability to work effectively with culturally and socioeconomically diverse patients, families, communities, and staff.
Strong organizational and project coordination skills, with the ability to manage multiple programs, priorities, deadlines, and follow-up activities with limited daily supervision.
Ability to combine direct patient and family support with administrative, programmatic, and data-tracking responsibilities.
Strong written and verbal communication skills and the ability to communicate with sensitivity, professionalism, and sound judgment.
Ability to respond to feedback and adjust approach according to recommendations from the supervisor or other program team members.
Ability to collaborate across clinical, behavioral health, social service, administrative, and community-based teams.
Ability to interpret program requirements and consistently follow established workflows, documentation standards, and funding restrictions.
Proficiency with Electronic Health Records, Microsoft Office or equivalent productivity tools, spreadsheets, and program tracking systems.
Ability to identify operational barriers, escalate concerns appropriately, and contribute practical recommendations for workflow and program improvement.
Ability to travel among FPCSN sites and community locations as required.
Ability to pass required background screenings.
Pennsylvania Child Abuse History Clearance, Pennsylvania State Police Criminal History Record Check, and FBI Criminal History Clearance required prior to start and maintained current, consistent with the Pennsylvania Child Protective Services Law.
Current valid CPR Certification is required.
Mandated reporter training required within 30 days of hire and maintained current.
Maintain reliable transportation to travel throughout the network, to family and community locations, and/or participate in events outside the network as needed.
Availability for occasional evening and weekend hours for community and screening events.
MEDIUM – Exerting up to 50 pounds of force occasionally, and/or up to 20 pounds of force frequently, and/or up to 10 pounds constantly to move objects..
Stand or Sit (stationary position)
Walk
Use hands or fingers to handle or feel (operate, activate, prepare, inspect, position)
Climb (stairs/ladders)
Talk/Hear (communicate, converse, convey, express/exchange information)
See (detect, identify, recognize, inspect, assess)
Pushing or Pulling
Repetitive Motion
Reaching (high or low)
Kneel, Stoop, Crouch, or Crawl (position self, move)
Regular travel among FPCSN sites, to family and community locations, and/or participation in events outside the network as needed.

Nice To Haves

Bachelor’s degree in community health, health sciences, health administration, social work, human services, or a related field preferred.
Experience in an FQHC, primary care, community health, behavioral health, or population health setting preferred.
Experience supporting grant-funded programs, program implementation, quality improvement, or funder reporting preferred.
Experience working with children and families, including children with developmental, behavioral health, chronic, or special health care needs, preferred.
Experience with cancer screening outreach, care gap closure, or chronic disease population management preferred.
Experience with athenahealth and a population health registry or analytics platform preferred.
Familiarity with Philadelphia-area health and human service systems, including Early Intervention, schools, Medical Assistance and HealthChoices managed care plans, behavioral health, transportation, and community-based services, preferred.
Fluency in a second language commonly spoken by FPCSN patients preferred.

Responsibilities

Coordinate day-to-day implementation of assigned Population Health grants and programs, initially including Title V CYSHCN and FOCUS.
Maintain program workplans, timelines, deliverables, enrollment or participation targets, activity trackers, and required program documentation.
Assist the Population Health Manager in translating grant requirements and program goals into practical workflows, tools, and outreach processes, and carry out those workflows once approved.
Coordinate program activities across FPCSN sites and support communication with internal teams and external partners as assigned by the Population Health Manager.
Track progress toward deliverables and proactively identify barriers, delays, risks, or unmet milestones for escalation to the Population Health Manager.
Prepare program materials, status updates, supporting documentation, and data summaries for internal meetings, funder meetings, monitoring activities, and reports.
Maintain awareness of program-specific requirements and ensure assigned activities are completed within approved scope, timelines, and funding restrictions.
Maintain organized program files, source documentation, and participant records in a monitoring- and audit-ready state.
Maintain inventory and documented distribution records for program supplies, kits, incentives, and materials, and provide usage information for budget monitoring and invoicing.
Complete funder-required onboarding, orientation, training, and program meetings as assigned.
Provide direct outreach, engagement, health education, patient navigation, and resource connection to patients and families served through assigned programs and Population Health initiatives.
Conduct needs and barriers assessments and assist patients and caregivers in addressing social, logistical, educational, and health-related barriers to care.
Connect patients and families to primary care, specialty care, behavioral health, developmental services, educational supports, insurance and benefits resources, transportation, food assistance, and community-based services as appropriate.
Assist patients and caregivers with scheduling, referral completion, appointment readiness, and follow-up; close the loop on referrals and escalate unresolved needs appropriately.
Assess transportation barriers and arrange vendor-paid transportation support in accordance with program policy, and assist families with Medical Assistance Transportation Program (MATP) applications. No cash payments or reimbursements are made to patients.
Support health literacy, self-management, preventive care, and understanding of care plans within the non-clinical scope of the role.
Where the incumbent holds Pennsylvania Certified Community Health Worker credentialing, deliver and document community health worker services consistent with Medical Assistance and managed care organization requirements, and maintain certification in good standing.
Participate in community outreach events, health fairs, family events, and other engagement activities across FPCSN and in the community.
Provide care coordination services for assigned patients or priority populations, including outreach, navigation, referral follow-up, barrier resolution, and coordination with interdisciplinary care teams.
Serve as a day-to-day point of information for FPCSN Care Coordinators on assigned grants and Population Health initiatives, including program workflows, referral pathways, documentation expectations, and program-specific requirements.
Support consistent use of Population Health program workflows across sites by sharing program-specific instructions, tools, and materials approved by the Population Health Manager.
Provide short-term coverage, surge support, or targeted assistance for care coordination functions when approved by the Population Health Manager.
Support cross-site coordination for high-priority patient populations and initiatives requiring consistent execution across multiple locations.
Bring recurring care coordination or workflow barriers to the attention of the Population Health Manager.
Escalate clinical concerns, safety concerns, and needs beyond the scope of the role to the Population Health Manager, the site Care Coordinator, or the patient’s provider.
Provide programmatic coordination and support without replacing the Population Health Manager’s supervisory responsibility for Care Coordinators.
Coordinate special projects assigned by the Population Health Manager, including new grant implementation, outreach campaigns, preventive health initiatives, population-specific programs, quality improvement projects, community partnerships, and pilot programs.
Support projects from planning and launch through implementation, monitoring, evaluation, and closeout.
Develop or maintain project plans, task lists, workflows, communication tools, educational materials, tracking systems, and other implementation resources.
Coordinate meetings, follow-up activities, partner communication, and action items associated with assigned initiatives.
Adapt to emerging departmental priorities and provide implementation support for new Population Health opportunities as they are developed.
Document patient and family contacts, assessments, referrals, interventions, outcomes, and program activities accurately and timely in the Electronic Health Record and approved tracking systems.
Maintain accurate grant and program data consistent with FPCSN, funder, HIPAA, and regulatory requirements.
Generate, validate, and work patient lists from the population health registry.
Monitor assigned program metrics, outreach activity, enrollment, service utilization, referrals, deliverables, and outcomes.
Conduct routine data-quality checks and follow up on missing, incomplete, or inconsistent documentation.
Compile data and narrative information for monthly, quarterly, annual, and funder-required reports.
Support data validation, chart review, audit, and monitoring activities conducted by funders, payers, or FPCSN.
Support the Population Health Manager in evaluating program performance, identifying trends, and implementing process or quality improvements.
Develop and maintain effective working relationships with community organizations, health and social service agencies, schools, behavioral health organizations, payers, and other partners relevant to assigned programs.
Participate in care team huddles, case conferences, Population Health meetings, grant meetings, trainings, and external partner meetings as assigned.
Attend internal or external workgroups and partner meetings on behalf of the Population Health Manager when specifically assigned, and report back on discussion and follow-up items.
Maintain a current community resource inventory for use across the department.
Communicate professionally and collaboratively with patients, caregivers, providers, Care Coordinators, leadership, funders, and community partners.
Identify, enroll, and serve families raising children with special health care needs toward the program enrollment target, with priority focus on children under five years of age, using provider referrals, care team referrals, and program-generated patient lists across all sites.
Complete initial family needs and barriers assessments and re-assess at defined intervals.
Connect families to Early Intervention, school-based services and IEP/504 supports, developmental evaluation, behavioral health intake, and specialty care.
Coach caregivers on care plans, condition management, and self-care.
Assemble, inventory, and distribute maternal and child health supply kits with accompanying education, and maintain accurate distribution records.
Administer program satisfaction and family experience surveys and support families in completing them.
Report on service contacts and provide aggregate demographic data, service outputs, and outcomes for baseline, quarterly, and annual Title V reporting to PACHC and the Pennsylvania Department of Health.
Conduct outreach to eligible patients, explain screening options, and support patients through kit ordering, completion, and return.
Track kit distribution, return, and result receipt, and re-engage patients who do not return a kit within defined intervals.
Notify the ordering provider and care team of abnormal results on the same business day.
Assist patients with abnormal results in scheduling and completing diagnostic colonoscopy, including support with transportation, preparation, insurance authorization, and specialty access, and follow each patient through to completion.
Compile screening and follow-up data for program reporting against baseline and target screening rates.