Population Health Analyst

About the role

Cornerstone Family Healthcare is a non‑profit Federally Qualified Health Center dedicated to providing high‑quality, comprehensive primary and preventive care to all people regardless of ability to pay. The Population Health Analyst supports population health and patient‑centered medical home (PCMH) initiatives, focusing on preventive outreach, pre‑visit planning, data monitoring, chart review, and collaboration with care teams to advance quality of care and meet incentive‑based goals.

Responsibilities

• Act as liaison with MCOs to evaluate data, perform preventive outreach, engage members, and coordinate care with internal teams.
• Conduct preventive outreach and engagement (reminder letters, follow‑up calls) to schedule patients for overdue preventive and chronic care services.
• Maintain tracking systems for outreach, reminders, and member engagement activities, ensuring timely follow‑up.
• Utilize and support pre‑visit planning tools, training staff and care teams on effective use.
• Coordinate member management activities with care teams within the electronic clinical workflow (ECW), including documentation and task coordination.
• Assist with PCMH workflows, care coordination processes, and team‑based care initiatives.
• Monitor patient and provider compliance with quality, risk, and PCMH measures; report performance, gaps, and risks to care teams, QI Coordinator, and Director of Quality Improvement.
• Perform chart reviews and support provider alerts to identify care gaps, risk factors, and quality improvement opportunities.
• Collaborate with QI providers to develop outreach and engagement plans for high‑risk patients.
• Review medical records and related documentation, providing feedback to support quality care delivery and measure accuracy.
• Coordinate HEDIS and other quality chart reviews onsite or remotely with MCOs related to incentive and reporting programs.
• Support scorecard development and reporting for all quality measures, including PCMH performance metrics.
• Assist with data gathering, validation, and report preparation to meet MCO, CHIPA, UDS, PCMH, and internal reporting requirements.
• Identify data discrepancies, validate data integrity, and submit help desk tickets as appropriate.
• Assist in training staff on reporting platforms (e.g., Azara, ECW) and recommend additional training based on performance and data review.
• Participate in CHIPA workgroup meetings and provide feedback to support workflow improvements and quality initiatives.
• Attend and participate in monthly department, All Staff, leadership, and other required meetings.
• Maintain confidentiality of all aspects of Cornerstone Family Healthcare (patient, financial, strategic, employee relations).
• Perform other related duties as assigned.

Requirements

• High school diploma or GED.
• Bilingual preferred.
• Highly organized with excellent oral and written communication skills.
• Minimum four years of experience in a healthcare setting.

Benefits

• Competitive salaries
• Health benefits
• Retirement plan
• Paid Time Off
• Sick Time
• Flexible Spending
• Dependent Care
• Paid Holidays

Pay

$28.58 per hour

Schedule

Full-time