Population Health Specialist

POSITION TITLE:        Population Health Specialist

RESPONSIBLE TO:     Chief Quality Officer

FLSA STATUS:            Non-Exempt

Purpose of Position: The Population Health Specialist supports the Quality Department in managing and improving the health of identified patient populations. The Population Health Specialist uses technology to address patient barriers to care, close care gaps, and track the health and care of Valley Family Health Care patients in accordance with the goals and mission of Valley Family Health Care. Activities will facilitate and support high quality and collaborative patient care delivery with the intended result in more cost-efficient care and improved patient outcomes.


  1. Two years or more experience in the fields of health, public health, or social service; an emphasis on population health and care coordination is desirable; a background in medical billing a plus
  2. High School diploma or equivalent.
  3. Knowledge of typical quality programs within Medicare, Medicaid, and commercial payors preferred.
  4. Excellent organizational skills and strong written and verbal communication skills.
  5. Strong computer skills, particularly in Microsoft Excel and Electronic Health Records.
  6. Able to build and maintain effective partnerships internally and externally with an awareness of community resources.
  7. Able to work with minimal supervision and maximum accountability to problem-solve and work independently and collaboratively as a member of a team.
  8. A neat and professional demeanor, with pleasant manner in telephone and personal contacts.
  9. Strong analytical skills with the ability to manage and prioritize multiple tasks.
  10. Fluent in written and spoken English. Spanish fluency is desirable.


  1. Support quality improvement initiatives, Chronic Care Management (CCM), and Transitional Care Management (TCM) services, through population health strategies, data collection, and patient tracking and reporting.
  2. Assist Care Coordinators/Case Managers by utilizing registries and electronic reports to support targeted populations. Track and determine patient case management needs.
  3. Assist with maintaining reporting requirements for QI recognition and value-based payment programs in line with the VFHC mission and goals.
  4. Review Medicare, Medicaid, & other Payer GAP reports and coordinate closing identified care gaps with payors, clinical care teams, and patients.
  5. Participate in data collection and health outcomes reporting related to patient centered care and VFHC quality improvement programs and initiatives.
  6. Maintain provider empanelment with accurate patient rosters and maintain registries for the identification of special populations within the total patient population.
  7. Promote clear communication among the integrated care team.
  8. Participate in other VFHC meetings and committees as assigned.
  9. Assist with meeting quality measures by completing tasks related to VFHC initiatives.
  10. Perform other duties as assigned.

Physical Requirements:

  1. Ability to lift 25lbs.
  2. Prolonged sitting/standing/walking/stooping, etc.
  3. Correctable vision and hearing.
  4. Manual dexterity.
  5. Must be able to read, write and speak clearly.


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