Population Health Coordinator

Quality Healthcare Development LLC•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 gaps in care, 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. This is an administrative and coordination-focused position; it does not independently perform clinical assessments, provide medical advice, or make treatment decisions. The position is primarily office-based or approved remote/hybrid, uses a computer, telephone, and EHR systems, and may require occasional travel to assigned practice locations or team meetings.

Requirements

High school diploma or equivalent required.
Experience using Electronic Health Records (EHR) required, 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.
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.
Understanding of preventive healthcare services, care gaps, and quality improvement processes.

Responsibilities

Review patient registries, EHR reports, and population health dashboards to identify outstanding preventive, chronic disease, and quality-related care gaps.
Conduct patient outreach to facilitate appointments, screenings, and recommended preventive services; coordinate with practice teams to support timely completion.
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, including reconciling documented services and identifying opportunities to close gaps through appropriate documentation.
Identify Medicare beneficiaries eligible or due for AWVs, explain the purpose of visits, coordinate scheduling, maintain completion records, and follow up on canceled or missed appointments.
Collaborate with practice leadership to support AWV participation and completion goals.
Request external medical records from hospitals, specialists, laboratories, imaging facilities, and other healthcare organizations; review them for completeness and relevant preventive or chronic care documentation.
Upload, index, and organize documents in the EHR, identify documentation supporting quality measure compliance, and route it for appropriate review and validation.
Maintain accurate records in compliance with HIPAA, confidentiality requirements, and organizational policies.
Monitor available hospital and emergency department admission, discharge, and transfer reports; notify the Nurse Care Coordinator or designated clinical team about patients requiring follow-up.
Assist with scheduling post-discharge follow-up appointments, track appointment completion, document coordination activities, and promptly escalate clinical concerns to qualified clinical personnel.
Maintain patient outreach, scheduling, medical record, and care gap tracking information; assist with preparing and validating population health reports and quality dashboards.
Monitor work queues, follow up on outstanding activities, collaborate with clinical operations, quality teams, and practice staff, and recommend process improvements to address recurring barriers.
Participate in team meetings, training, and quality improvement initiatives, and perform other related duties as assigned.