Population Health Specialist II

CareMore Health•Henderson, NV

16h•$21 - $32•Hybrid

About The Position

The Population Health Specialist (PHS) at CareMore Health plays a vital role in advancing a value-based care model focused on improving health outcomes, enhancing patient experience, and reducing the total cost of care. This role serves as a trusted liaison between patients, care teams, and community resources. The PHS works to address social determinants of health (SDOH), remove barriers to care, and support patient engagement through outreach, education, and care coordination.

Requirements

High School diploma or GED required
Minimum of 1 year of experience in healthcare, community-based services, or social services, or equivalent combination of education and experience
Experience using electronic medical records (EMR)

Nice To Haves

Bilingual skills preferred
Certified Community Health Worker (CCHW) preferred
Experience working in a value-based care and/or population health environment

Responsibilities

Serve as a liaison between patients, caregivers, interdisciplinary care teams, and community-based organizations to support whole-person, value-based care.
Conduct telephonic and in-person outreach to an assigned patient panel to schedule appointments, complete needs assessments, and support closure of care gaps aligned with quality and population health metrics.
Meet patients in clinic, facility, or home settings to identify and address social determinants of health (SDOH) impacting health outcomes and utilization.
Collaborate with care managers, social workers, and providers to develop and implement patient-centered care plans.
Build trusted relationships with patients to drive engagement, adherence, and improved health outcomes.
Assist patients in navigating healthcare and community systems, including coordination of specialty care, appointment support or accompaniment (as appropriate), and assistance with enrollment forms and benefits.
Connect patients to community resources (e.g., food, housing, transportation, behavioral health) to reduce barriers and prevent avoidable utilization.
Facilitate communication among patients, families, providers, and community partners to ensure coordinated care.
Document all patient interactions in the electronic medical record (EMR) in accordance with organizational and regulatory standards.
Participate in interdisciplinary team meetings, case conferences, and population health initiatives.
Support efforts to reduce emergency department visits, hospital admissions, and readmissions through proactive outreach and engagement.
Travel within the community to meet patients where they are.