Population Health Care Coordinator

Job description

Title: Population Health Care Coordinator
FLSA Category: Non-Exempt
Reports To: Population Health Manager
Greater Baden Medical Services (GBMS) is a Federally Qualified Health Center (FQHC) dedicated to providing high-quality healthcare across Southern Maryland. With 9 clinical sites across Prince George's, Charles, and St. Mary's counties, we serve over 18,000 patients each year. We provide fully integrated care that includes primary care, pediatrics, women's health, Title X family planning, dental care, behavioral health, WIC, pharmacy services, and the Ryan White HIV/AIDS program. Our patient population is primarily made up of Medicaid and uninsured individuals. We are deeply proud to deliver these vital services to everyone in our community, regardless of their ability to pay, making Greater Baden an incredibly rewarding place to grow your career while making a tangible, life-changing impact every day.
Job Summary:
The Population Health Patient Outreach Coordinator specializes in re-engaging historically disengaged, non-compliant, and hard-to-reach patients attributed to our FQHC through Managed Care Organization (MCO) rosters. Functioning as a dedicated digital and telephonic engagement expert, the coordinator utilizes data registries provided by Population Health Manager to execute targeted outreach campaigns, close critical HEDIS care gaps, arrange clinic-based appointments, and resolve initial barriers to care. Additionally, this role actively participates in outreach events in collaboration with the Population Health team to support patient engagement and community health initiative
Essential Functions:
• MCO List Penetration: Systematically scrub and work high-volume, monthly Medicaid and Medicare MCO patient attribution rosters to locate and contact patients with zero healthcare footprint over the past 12–24 months.
• Cold Engagement Campaigns: Execute multi-channel, persistent outreach workflows (including high-volume calling, secure texting, and digital portal messaging) tailored to re-introduce the FQHC's medical, dental, and behavioral health services to disengaged members.
• Barriers to Care Assessment: Conduct telephonic screenings during initial contact to discover underlying reasons for disengagement, such as loss of insurance coverage, communication barriers, scheduling fears, or mistrust of clinical environments.
• Insurance & Benefit Assistance: Provide basic telephonic navigation to assist patients who have mistakenly slipped from active MCO rosters, facilitating connections to internal financial counselors or eligibility specialists.
• Targeted Campaign Execution: Under the direction of Population Health, deploy focused telephonic campaigns synchronized with quality improvement cycles targeting specific HEDIS measures (e.g., childhood immunizations, diabetic A1c screenings, cervical/colorectal cancer screenings).
• Direct Care Booking: Navigate the EHR system in real-time to secure, reschedule, or change appointments for patients, executing high-priority warm-transfers to clinical teams or scheduling grids.
• Pre-Appointment Prep: Provide comprehensive pre-visit instructions over the phone to ensure re-engaged patients understand arrival times, sliding fee scale documentation requirements, and necessary clinical pre-requisites.
• CRISP & Notification Follow-Up: Receive daily lists of recent hospital admissions and emergency department discharges generated via CRISP (Health Information Exchange) panel alerts and conduct rapid phone outreach, in coordination with the nursing team, to establish timely follow-up appointments.
• EHR Documentation: Log all patient interactions, refusal reasons, disconnected numbers, and successful bookings within the center's electronic health record software to maintain data integrity.
• Internal Cross-Functional Hand-offs: Coordinate smooth hand-offs to Population Health Nurses for complex clinical cases or to on-site Community Health Workers (CHWs) for patients requiring immediate in-clinic social determinant interventions.
• Community & Team Outreach Events: Actively participate in outreach events in collaboration with the Population Health team to drive community engagement, register disengaged patients, and promote primary care services.

Nonessential Functions:
• Helps with scanning and filing medical test results and other documentation into the medical record.
• Retrieves voicemails, takes messages from patients, and enters EMR and routes appropriately.
• Performs clerical duties such as filing, photocopying, and collating.
• Participates in team/staff meetings; monthly meetings with Managed Care Organizations; and attends in service meetings and applicable workshops.
• Performs other duties as assigned by supervisor.

Managerial Responsibilities- None
Minimum Qualifications:
• High School diploma, GED, or equivalent certification of competency.
• Previous experience with appointment scheduling within a medical office setting.
• Familiarity with basic medical terminology.

Preferred Qualifications:
• Certificate of completion from an accredited Medical Assisting Program.

Core Competencies Needed:
Accountability – Meets established expectations and takes responsibility for achieving results; encourages others to do the same.
Customer Focus – Connects meaningfully with customers to build emotional engagement and patient advocacy. Simplifies complexity and integrates internal efforts to deliver an optimal customer experience.
Healthcare Systems – Knowledge of healthcare and medical terminology
Organization – Effectively managing tasks and information and organize information to ensure a timely response to questions. Develops and uses systems to organize and keep track of information or work progress.
Work Environment
This job operates in a professional office environment. This role routinely uses standard office equipment such as computers, phones, photocopiers, filing cabinets and fax machines .
Physical and Mental Demands
• Ability to remain in a stationary position 50% of the time.
• Ability to cope with stress.
• Constantly operates a computer and other office productivity machinery, such as a calculator, copy machine and computer printer.
• The person in this position frequently communicates with patients and/or employees. Must be able to summarize and exchange accurate information.
• Performs a variety of duties, often changing from one task to another.
• Performs with frequent interruption or distractions.
• Adjust priorities quickly as circumstances dictate.
• Ability to interact appropriately with colleagues for different purposes in different context.
• Expressing or exchanging information to convey detailed spoken instructions accurately, or quickly.
• Ability to judge distances and spatial relationships to see objects where and as they actually are.
• Cognitive ability to analyze, count, summarize and synthesize information from multiple sources.

Language Skills
Ability to read and interpret written or verbal documents and instructions. Ability to speak effectively to patients, employees and/or stakeholders of the organization.
Compliance
This position requires compliance with Greater Baden Medical Services (Health Center’s) compliance standards, including its Standards of Conduct, Compliance Program, and policies and procedures. Such compliance will be an element considered as part of the Population Health Manager regular performance evaluation.
Travel
Must be able to drive between Greater Baden Medical Services, Inc. locations