Population Health Specialist

The Population Health Specialist is responsible for supporting CHIPA’s partner organizations in achieving quality improvement outcomes across numerous payor programs through practice coaching and transformation support.  The Population Health Specialist role is a hands-on position leading their assigned practices in improving Key Performance Indicators (KPIs) outlined in CHIPA’s Value Based Payment (VBP) agreements.  These KPIs include clinical quality measures, membership engagement, facility utilization, and costs measures.

Responsibilities:  Practice Development and Quality Improvement

  • Helps practices adopt, transform, and sustain CHIPA’s value-based model of care.
  • Acts as a principal contact for partner FQHCs.
  • Establishes a strong and positive culture of collaboration with assigned CHIPA partner FQHCs, including but not limited to:
    • Educating and training teams on quality measures specifications, including knowledge of appropriate billing codes and/or documentation needed by the payor to meet the measure.
    • Designing, implementing, and monitoring quality improvement processes, including continuous assessment of challenges in achieving stated goals.
    • Coordinates additional training initiatives needed by the FQHC, such as in the Population Health analytics tool and its application.
  • Assesses the capability of the FQHC to meet VBP contract goals, considering its resources and experience around KPIs.
  • Maintains a reporting system to measure success and areas for improvement during the implementation and maintenance phases of transformation.  Assists in creating performance dashboards and facilitating the request of custom reports to ensure the success of partners. 
  • In collaboration with CHIPA partners, develop an outreach plan of action and follow-up for each quality measure to maximize contract terms.
  • Recommend resources that may be helpful to their assigned practice’s patient population, such as access to community resources, and self-management materials in multiple languages.
  • Building and coordinating innovative partnerships with multiple stakeholders (i.e. sharing best practices among partners), and when appropriate, assisting practices with patient engagement efforts (i.e. via Blaze Campaign Builder).
  • Recommends changes in workflows and adoption of new technologies (i.e. texting platforms and retinal imaging camaras) at partner sites.  Identifying new/needed skills, processes, or methods to support a culture of performance improvement (i.e. project management and change management training).
  • Remains knowledgeable regarding the most up to date measure specifications for each contract measure.
  • When appropriate, research additional best practices to help with improvement initiatives.  Coordinate meetings (in person or virtually) with staff for the purposes of training, and to discuss the performance of selected projects. 

Responsibilities:  Data Analytics & Reporting

  • Coordinates practice training on the data analytics platform and makes recommendations for additional staff training.  Coaches practices to independently access, analyze, and utilize the platform to review their performance on KPIs. 
  • Monitor performance of the clinical measures set forth by each VBP agreement at the FQHC-level, and at least on a quarterly basis, produces and analyzes KPI reports to identify measure trends, strengths and areas needing performance improvement plans.  Provides feedback of such performance and analysis with their assigned practice.
  • Validates MCO and analytics platform data to ensure integrity of information and data hygiene using data mining techniques.  Works with the appropriate liaison to achieve data accuracy.
  • On a monthly basis, reports practice-level performance information on KPIs with the VP of Population Health to support decision-making efforts.


Minimum Qualifications:

  • Five years of relevant experience
  • Highly organized with excellent oral and written communication skills
  • Able to manage multiple tasks and projects simultaneously
  • Excellent interpersonal, troubleshooting, and decision-making skills
  • Comfortable with continuous changes and self-initiating
  • Proficiency with Microsoft Office Suite (e.g., Excel, Word, Outlook)
  • Experience with electronic health records. 
  • Ability to maintain a non-judgmental disposition and communicate with a diverse population.

Preferred Qualifications:

  • Previous experience with quality improvement process
  • Understanding of medical billing and coding in a practice setting
  • Basic knowledge of payor claims processes
  • Basic knowledge of Project Management
Job Category: Population Health
Job Type: Full Time
Job Location: Remote

Apply for this position

Allowed Type(s): .pdf, .doc, .docx


FQHC's can find support and resources by joining CHIPA with other FQHC's.

  • This field is for validation purposes and should be left unchanged.