Population Health Supervisor

SACRAMENTO NATIVE AMERICAN HEALTH CENTER INC•Sacramento, CA

35d•$28 - $30•Onsite

About The Position

The Population Health Supervisor reports to the Medical Clinic Manager and oversees care coordination functions for the clinic operations. Leads panel management, care gap closure, transitions of care, closed loop referrals, linkages to community resources. Uses the EHR and registry tools to identify unmet needs, drive preventive and chronic care outreach, and track results. Aligns teamwork with quality, access, and compliance goals. Partners with the Clinic Manager, Operations, payers, and community partners to improve outcomes and patient experience. Essential Functions Lead daily care coordination operations. Set priorities and deploy staff to meet panel and outreach goals. Manage schedules, timekeeping, training, and performance feedback. Run panel and registry reports in the EHR and population health tools. Validate attribution and outreach lists. Close care gaps using standing protocols. Coordinate with providers and front desk staff to schedule needed services. Manage transitions of care. Complete post-discharge outreach within two business days. Document and escalate issues as needed. Monitor referral workflows. Ensure authorizations, appointments, and results are completed and filed. Track closed-loop rates. Coordinate with health plans and community partners on ECM, CCM, and related programs. Meet all program requirements and timelines. Standardize care coordination workflows in collaboration with QI. Create job aids and checklists. Verify staff competency and compliance. Track HEDIS and UDS measures relevant to care coordination. Share weekly and monthly dashboards. Support service recovery for escalated patient concerns related to access, referrals, authorizations, or navigation. Maintain accurate documentation in the EHR, care management platforms, and plan portals. Ensure compliance with HIPAA, 42 CFR Part 2, OSHA, AAAHC, and payer program requirements. Lead team huddles and case reviews. Align actions with provider plans of care. Recruit, onboard, and develop staff. Apply progressive discipline when appropriate. Collaborate with the Clinic Supervisor I to balance clinic flow, staffing, and outreach priorities. Run and analyze registry and panel reports for priority conditions, show rates, cancellations, and outreach. Identify trends and gaps. Lead pre-visit planning and huddles to align required services with scheduled encounters. Implement standard protocols to close gaps in preventive and chronic care. Document actions and results. Manage recalls, follow-ups, ER and hospital discharge outreach, and Initial Health Assessment coordination. Coordinate outreach to newly Medicare-eligible patients and provide education on the medical home, patient portal, and team-based care. Validate panel attribution and outreach lists. Reconcile variances with providers and health plans. Partner with QI to design and implement population health workflows, job aids, and audits. Monitor referral completion and closed-loop communication with care teams. Maintain accurate documentation in EHRs, registries, and plan portals. At all times demonstrates cooperative behavior with supervisors, clients, colleagues and the community. Participate in internal quality improvement teams. Works with team members proactively to drive quality improvement initiatives in accordance with the mission and strategic goals for the organization, federal and state laws and regulations, and accreditation standards. Serve as liaison with clinical teams, patient services, and external partners to remove barriers to care. Ensure compliance with HIPAA, OSHA, AAAHC, payer program rules, and organizational policies. Other duties as assigned.

Requirements

Associate degree in health, social services, or related field, or equivalent experience.
Experience working in an Electronic Health Record environment.
Knowledge of issues affecting people experiencing homelessness, low-income families, individuals with mental health needs, and justice involved populations.

Nice To Haves

Bachelor’s degree in health, social services, or related field, or four years of related work experience
Two or more years of experience as a Medical Assistant.
Experience in an FQHC setting.
Proficiency with NextGen and related administrative or registry systems.
Knowledge of Social Determinants of a Health Work Environment

Responsibilities

Lead daily care coordination operations.
Set priorities and deploy staff to meet panel and outreach goals.
Manage schedules, timekeeping, training, and performance feedback.
Run panel and registry reports in the EHR and population health tools.
Validate attribution and outreach lists.
Close care gaps using standing protocols.
Coordinate with providers and front desk staff to schedule needed services.
Manage transitions of care.
Complete post-discharge outreach within two business days.
Document and escalate issues as needed.
Monitor referral workflows.
Ensure authorizations, appointments, and results are completed and filed.
Track closed-loop rates.
Coordinate with health plans and community partners on ECM, CCM, and related programs.
Meet all program requirements and timelines.
Standardize care coordination workflows in collaboration with QI.
Create job aids and checklists.
Verify staff competency and compliance.
Track HEDIS and UDS measures relevant to care coordination.
Share weekly and monthly dashboards.
Support service recovery for escalated patient concerns related to access, referrals, authorizations, or navigation.
Maintain accurate documentation in the EHR, care management platforms, and plan portals.
Ensure compliance with HIPAA, 42 CFR Part 2, OSHA, AAAHC, and payer program requirements.
Lead team huddles and case reviews.
Align actions with provider plans of care.
Recruit, onboard, and develop staff.
Apply progressive discipline when appropriate.
Collaborate with the Clinic Supervisor I to balance clinic flow, staffing, and outreach priorities.
Run and analyze registry and panel reports for priority conditions, show rates, cancellations, and outreach.
Identify trends and gaps.
Lead pre-visit planning and huddles to align required services with scheduled encounters.
Implement standard protocols to close gaps in preventive and chronic care.
Document actions and results.
Manage recalls, follow-ups, ER and hospital discharge outreach, and Initial Health Assessment coordination.
Coordinate outreach to newly Medicare-eligible patients and provide education on the medical home, patient portal, and team-based care.
Validate panel attribution and outreach lists.
Reconcile variances with providers and health plans.
Partner with QI to design and implement population health workflows, job aids, and audits.
Monitor referral completion and closed-loop communication with care teams.
Maintain accurate documentation in EHRs, registries, and plan portals.
At all times demonstrates cooperative behavior with supervisors, clients, colleagues and the community.
Participate in internal quality improvement teams.
Works with team members proactively to drive quality improvement initiatives in accordance with the mission and strategic goals for the organization, federal and state laws and regulations, and accreditation standards.
Serve as liaison with clinical teams, patient services, and external partners to remove barriers to care.
Ensure compliance with HIPAA, OSHA, AAAHC, payer program rules, and organizational policies.
Other duties as assigned.