Population Health Management Coordinator

About the role

The Population Health Management Coordinator (PHMC) contributes to AHF by blending the mission with care coordination. The PHMC works in conjunction with the Population Health Management Registered Nurse to ensure that all members have access to a comprehensive set of services based on their needs and preferences across the continuum of care. This position plays a vital role in advancing care quality, access, and outcomes by bridging gaps between clinical services and community-based resources through direct field engagement.

The PHMC is responsible for conducting in-person visits to provider offices, community organizations, and high-risk member populations to support care coordination, promote adherence to evidence-based guidelines, and address social determinants of health. The role enhances AHF’s reputation by impacting improved member health outcomes and health equity, leading to longer, healthier, and happier lives. The PHMC serves as a passionate advocate for AHF’s top initiatives while ensuring the organization’s Core Values and Mission remain central to all efforts.

AHF operates in a dynamic environment with a collaborative organizational structure where staff are accountable to multiple leaders. The PHMC will work as part of a close-knit team to identify the needs, challenges, and barriers of the patient population and assist members with accessing appropriate health plan benefits and community resources, demonstrating a caring, compassionate, and knowledgeable focus.

Responsibilities

• Collaborate with interdisciplinary teams to identify care gaps, facilitate timely interventions, and ensure continuity of care, particularly for vulnerable and high-utilization populations.
• Conduct in-person visits to provider offices, community organizations, and high-risk member populations to support care coordination and promote adherence to evidence-based guidelines.
• Address social determinants of health through direct field engagement and relationship building.
• Enhance member engagement through data-driven outreach and real-time problem solving in the field.
• Reduce avoidable emergency department utilization and support organizational quality metrics and value-based care initiatives.
• Assist members with accessing appropriate health plan benefits and community resources.
• Maintain a focus on AHF’s Core Values and Mission in all activities.

Requirements

• Managed Care experience preferred.
• Bilingual (Spanish) required.