Population Health Specialist

Job Description

Position Summary

The Population Health Specialist supports Akido's value-based care strategy by identifying, engaging, and coordinating care for patient populations requiring preventive services, chronic disease management, and care gap closure. This role collaborates with providers, clinic teams, health plans, and patients to improve quality outcomes, patient engagement, continuity of care, and access to services.

The Population Health Specialist utilizes population health tools, patient registries, quality reports, and outreach workflows to support HEDIS, STAR, risk adjustment, Annual Wellness Visits, and other quality initiatives while contributing to organizational performance and patient health outcomes.

Essential Functions

• Conduct patient outreach and engagement activities to close preventive and chronic care gaps.
• Coordinate appointments, screenings, referrals, and follow-up services.
• Support organizational quality improvement and value-based care initiatives.
• Maintain accurate patient documentation and outreach records.
• Collaborate with interdisciplinary teams to address barriers to care.
• Monitor and track performance metrics related to population health outcomes.
• Support patient retention, engagement, and continuity of care efforts.

Key Responsibilities

Population Health & Care Gap Management

• Identify patients with open quality, preventive, and chronic care gaps through approved reports, registries, and work queues.
• Conduct outreach through phone calls, text messaging, patient portals, and other approved communication channels.
• Coordinate Annual Wellness Visits, preventive screenings, immunizations, specialty referrals, chronic disease follow-up, and diagnostic testing.
• Document outreach efforts, patient responses, barriers, and intervention outcomes accurately and timely.
• Prioritize patient outreach based on clinical risk, health plan requirements, and organizational goals.

Patient Engagement & Care Coordination

• Serve as a primary point of contact for assigned patient populations.
• Educate patients on preventive care recommendations and available healthcare resources within scope of practice.
• Assist patients with scheduling, referrals, transportation resources, and healthcare navigation needs.
• Collaborate with clinical and operational teams to address barriers impacting care completion.
• Escalate clinical concerns and complex patient needs to the appropriate licensed team members.

Quality & Value-Based Care Support

• Support HEDIS, STAR, risk adjustment, Medicare Advantage, Medi-Cal, and other value-based care initiatives.
• Review quality reports and assigned patient lists to identify intervention opportunities.
• Assist with chart review, data validation, documentation improvement, and quality audits.
• Monitor progress toward care gap closure and quality performance goals.
• Follow standardized workflows to ensure accurate quality reporting and compliance.

Data Management & Reporting

• Maintain accurate records within the electronic health record (EHR) and population health platforms.
• Track outreach volume, completion rates, and unresolved patient barriers.
• Prepare routine reports and communicate trends, risks, and workflow issues to leadership.
• Maintain confidentiality and comply with HIPAA, privacy, and security regulations.

Collaboration & Continuous Improvement

• Work collaboratively with physicians, advanced practice providers, nurses, medical assistants, referral coordinators, and clinic operations teams.
• Participate in team meetings, quality reviews, and process improvement initiatives.
• Support implementation of new population health programs and workflow enhancements.
• Perform other duties as assigned.

Required Qualifications

• High School Diploma or equivalent required.
• Minimum two (2) years of experience in healthcare operations, population health, patient outreach, care coordination, managed care, or quality improvement.
• Experience utilizing EHR/EMR systems and Microsoft Office applications.
• Strong communication, customer service, organizational, and problem-solving skills.
• Ability to manage multiple priorities in a fast-paced, metric-driven environment.
• Ability to work effectively with diverse patient populations and interdisciplinary teams.
• Knowledge of HIPAA and patient privacy requirements.

Preferred Qualifications

• Associate's or Bachelor's degree in Public Health, Healthcare Administration, Nursing, Business Administration, or related field.
• Experience with HEDIS, STAR ratings, risk adjustment, Medicare Advantage, Medi-Cal, ACOs, or value-based care programs.
• Experience using population health software, patient registries, or quality reporting platforms.
• Knowledge of medical terminology and healthcare referral workflows.
• Experience working within a multi-site medical group environment.
• Bilingual English/Spanish preferred.

Physical Requirements

• Ability to sit and/or stand for prolonged periods of time.
• Ability to move/carry objects up to 20 pounds.
• Moving from one work site to another as needed.
• Ability to communicate with others to exchange information.
• Ability to use and/or type on a laptop/keyboard.

Ability to utilize telephone and computer systems throughout the workday

Benefits

• Stock-options package
• Health benefits include medical, dental and vision
• 401K
• Long-term disability
• Unlimited PTO
• Life insurance
• Paid Leave Program

Physical Demands: Mostly sedentary work duties require exerting up to thirty pounds of force occasionally and/or small amounts of force frequently. Sedentary work typically involves sitting most of the time but may involve walking or standing for brief periods.

Salary range