Quality - Quality and Population Health Coordinator (On-Site)

San Diego American Indian Health Center•San Diego, CA

20h•Onsite

About The Position

We are an FQHC community health center dedicated to embodying the values central to American Indian cultures. This includes respect for our patients, acknowledgement of the whole person, and a focus on working together to ensure health for the individual, and therefore the community. We invite persons of all tribes, ethnic backgrounds and walks of life to experience the comprehensive care we deliver and to contribute to the services we provide for children, youth, families, adults, and elders. The Quality & Population Health Coordinator supports organizational quality improvement and population health initiatives through proactive patient outreach, care gap closure activities, referral follow-up, panel management support, and preventive care coordination. This position works assigned outreach lists, supports patient engagement workflows, performs documentation and tracking activities, and assists with quality reporting processes related to HEDIS, GPRA, UDS, HRSA, managed care, value-based care, and grant-specific performance measures. The role collaborates with clinical and operational teams to improve continuity of care, preventive service completion, chronic disease management outcomes, and patient retention while ensuring outreach activities are timely, accurate, and well-documented. This position performs non-clinical outreach, engagement, scheduling support, and quality workflow coordination activities and does not provide clinical assessment, medical advice, or independent care management services.

Requirements

High School Diploma or GED (equivalent).
2-3 years related experience and/or training, or equivalent combination of education and experience.
CPR/ BLS certification: Maintain a current Basic Life Support (BLS) certification issued by the American Heart Association (AHA), the American Red Cross, or an equivalent organization. Certification must include an in-person, hands-on skills assessment. Online-only certifications are not accepted.
Annual background checks: Consent to annual background checks as a condition of continued employment, to ensure compliance with organizational standards and eligibility requirements.
For-Cause Drug Screening: Comply with drug screening requirements when initiated by the organization for cause, to support a safe, compliant, and drug-free workplace.
Ongoing Compliance Requirements: Maintain up-to-date compliance with all required annual renewals, including professional licenses, certifications, physical examinations, TB testing, and mandatory regulatory trainings as assigned by the San Diego Community Health Center (SDCHC).
Strong oral and written communication skills.
Exceptional time management skills
Highly organized and attention to detail.
Capable of maintaining confidentiality and accurate record-keeping.
Strong interpersonal skills.
Ability to interact effectively with diverse individuals.
Demonstrates the ability to establish and sustain cooperative working relationships throughout the course of work.
Competence in performing basic mathematical calculations is necessary for job responsibilities.
Dependable and highly trustworthy.
Proficiency in Microsoft office suite or similar software programs.
Understanding of population health management principles, preventive care initiatives, and quality improvement workflows.
Ability to interpret outreach reports, care gap lists, quality dashboards, and assigned patient worklists.
Ability to prioritize outreach efforts based on organizational quality goals and operational priorities.
Knowledge of patient engagement strategies that support improved clinical outcomes and continuity of care.
Ability to lift and move up to 10 pounds and navigate between locations as needed.
Capability to remain seated at a desk and operate a computer for extended periods.
Physical stamina to stand, bend, and reach for prolonged durations.
Strong analytical skills, with the ability to perform mathematical calculations, organize and prioritize tasks, and maintain productivity under pressure.
Demonstrated ability to supervise, manage multiple tasks simultaneously, and comprehend and follow instructions accurately.

Nice To Haves

Experience serving a multinational, multicultural population.
FQHC background.
Familiarity with Community Health Clinics and/or Indian Health Clinics.
ECW EHR.
Knowledge of HEDIS, GPRA, UDS, HRSA quality measures, value-based care initiatives, and population health workflows preferred.
Experience with care gap closure outreach, quality improvement initiatives, or population health programs preferred.
Familiarity with ECW registries, payer gap reports, quality dashboards, and preventive care outreach workflows preferred.

Responsibilities

Coordinate and execute proactive outreach to patients to support follow-up care, re-engagement, closure of quality care gaps, and referral completion.
Prioritize and manage patient engagement worklists, including but not limited to: health plan identified care gaps, missed appointments, overdue preventive services, telehealth follow-ups, referral tracking/scheduling, and newly assigned patients.
Ensure timely and consistent follow-through on all assigned outreach activities, including tracking, resolution, and appropriate escalation of unresolved cases.
Serve as the primary point of accountability for assigned patient engagement workflows, ensuring alignment with quality improvement goals and performance measure targets.
Conduct targeted outreach campaigns focused on high-priority organizational quality measures, including but not limited to diabetes management, hypertension follow-up, colorectal cancer screening, cervical cancer screening, breast cancer screening, depression screening, behavioral health follow-up, immunizations, and chronic disease management initiatives.
Utilize payer gap reports, ECW registries, quality dashboards, assigned worklists, and population health tools to identify and prioritize patients requiring intervention for HEDIS, GPRA, HRSA, UDS, and value-based care measures.
Coordinate with providers, nursing staff, behavioral health, referral coordinators, and care teams to facilitate timely closure of identified care gaps and completion of preventive services.
Support panel management and patient retention initiatives through outreach to overdue, attributed, empaneled, high-risk, and medically complex patients.
Coordinate appointment scheduling using ECW in accordance with provider templates, access protocols and efforts to close identified care gaps and support quality measure completion.
Guide patients through scheduling processes, setting expectations for preventive, follow-up, and referral-based services to support timely care delivery.
Support patients in understanding next steps in their care pathway, including preventive screenings, chronic care follow-up, and completion of recommended services.
Identify, document, and escalate scheduling barriers or access constraints to leadership to support improved access and continuity of care.
Coordinate scheduling efforts to maximize same-day care gap closure opportunities and completion of preventive services during patient visits.
Assist with pre-visit planning workflows to identify open care gaps, overdue screenings, referral needs, and chronic disease follow-up opportunities prior to scheduled appointments.
Accurately document all patient outreach attempts, communication outcomes, and coordination activities in in the Electronic Health Record (EHR).
Perform data entry and basic data validation to ensure accuracy, completeness, and integrity of quality and engagement data.
Track and maintain detailed outreach outcomes and external referrals, including follow-up to support completion, retrieval of supporting documentation, and appropriate care coordination to support performance monitoring and follow-up efforts.
Support medical record reviews and reporting activities to validate quality measure compliance and provide accurate data for operational review and performance monitoring accountability.
Support quality reporting validation activities related to HEDIS, GPRA, UDS, HRSA, managed care, and organizational performance measures.
Assist with obtaining and documenting external medical records, specialist reports, screening results, hospital documentation, and referral outcomes required for quality measure closure and reporting compliance.
Monitor assigned outreach and quality performance reports and escalate unresolved barriers impacting organizational quality goals.
Promote a positive patient experience through respectful, culturally responsive communication.
Educate patients on SDCHC services and programs.
Other duties as assigned based on department needs.
Actively champions and upholds the Mission, Vision, and core values of SDCHC through consistent actions and commitment.
Demonstrates outstanding customer service in all interactions with internal and external stakeholders, fostering positive and respectful relationships.
Embodies SDCHC’s Standards of Customer Service Behavior, including Compassion, Positive attitude, Effective Communication, Professional Appearance, a Strong Sense of Ownership, and Collaborative Teamwork.
Continuously engages in customer service training and professional development to enhance skills and maintain best practices.
Proactively promotes SDCHC’s reputation as a leading service organization through every interaction, demonstrating professionalism and dedication.
Actively contributes to the organization's success by engaging in quality improvement initiatives and demonstrating a commitment to continuous enhancement of services.
Strictly adhere to all SDCHC policies and procedures while proactively supporting the adoption and implementation of new organizational initiatives.
Participate in and champion ongoing quality improvement efforts as directed by clinic leadership, fostering a culture of excellence and innovation.
Maintain strict compliance with all regulations, policies, and procedures related to safe work practices, consistently prioritizing workplace safety.
Actively engage in infection prevention by adhering to best practices and implementing appropriate infection control measures during patient care and interactions.
Ensure full compliance with regulatory standards to maintain the safety of the physical environment, including equipment and supplies, promoting a secure and hazard-free workspace.
Utilize all necessary tools and equipment effectively to uphold workplace safety and reduce potential risks.
Promptly identify and report any unsafe working conditions to ensure immediate corrective action and maintain a safe working environment.
Upholds the highest standards of privacy and security for all patients, employees, and volunteers by strictly granting access to information solely on a need-to-know basis for legitimate business purposes.
Demonstrates unwavering commitment to corporate integrity by adhering to all relevant regulations and promptly reporting any unethical, fraudulent, or unlawful behavior or activities.
Consistently exemplifies the highest ethical standards in all professional interactions and decision-making processes.
Safeguards the confidentiality and security of patient and employee information with the utmost integrity, maintaining trust and accountability by allowing access strictly for business-related needs.