Population Health Program Manager

Job Summary

The Population Health Program Manager provides strategic and operational leadership for population health and care management services across clinic sites. This role is responsible for the development, oversight, and continuous improvement of programs that support patient engagement, care coordination, management of high-risk populations, and improved health outcomes across the continuum of care.

Essential Functions/Major Duties And Responsibilities

• Collaborate with clinical and operational leadership to identify population health priorities and develop strategies to improve preventive care, chronic disease management, care engagement, and equitable health outcomes.

• Provide system-wide leadership and oversight of all care management services across clinic sites, ensuring standardized, efficient, and high-quality care coordination processes.

• Oversee multidisciplinary care management teams, including general care management, behavioral health, pediatrics, transitions of care, school-based services, healthcare for the homeless, and insurance enrollment/resource navigation.

• Develop, implement, and continuously improve care management workflows, policies, and standard operating procedures across programs and sites.

• Support risk stratification, registry development, and proactive care engagement strategies to identify and manage high-risk and rising-risk patient populations.

• Partner with the Quality Improvement to develop and implement targeted care management strategies to improve outcomes, support performance improvement initiatives tied to clinical quality measures (e.g., UDS, HEDIS, value-based care metrics).

• Collaborate with clinic leadership to align care management strategies with clinical priorities, driving improved care coordination, reduced gaps in care, and enhanced patient engagement.

• Lead or support quality improvement initiatives, including PDSA cycles and innovation projects related to care management and patient engagement.

• Ensure standardized, high-quality care coordination across the continuum (outpatient, inpatient, ED, and community-based settings), including transitions of care and support for complex, chronic, behavioral health, and pediatric populations to improve engagement and outcomes.

• Utilize data tools (e.g., EHR registries, dashboards, internal reporting) to monitor program performance, patient outcomes, and care management impact, and regularly review and act on performance and utilization reports.

• Provide leadership and supervision to care management staff, including hiring, onboarding, training, performance management, and professional development, while establishing clear expectations for productivity, documentation, and patient engagement.

• Collaborate with clinic managers to provide orientation and ongoing training to their Care team staff.

• Lead and facilitate regular staff meetings, training sessions, and cross-functional collaboration efforts to ensure effective communication, team building, and ongoing staff development.

• Prioritize and allocate workload to achieve maximum efficiency and productivity.

• Ensure compliance with HRSA, PCMH, FTCA, and other regulatory and grant requirements by overseeing documentation standards, care management billing and reporting workflows, program policies and procedures, and participation in risk management activities, including incident reporting, investigation, and follow-up.

• Address client and service provider complaints and resolve complex issues. Direct complaints and incidents to Program Director after resolution process.

• Participate in budget planning and resource allocation for care management services.

• Serve as a key liaison across care management, clinical teams, leadership, and community partners, facilitating effective communication, collaboration, and coordination of services.

• Build and maintain effective relationships with other RiverStone Health service lines to ensure awareness and coordination of services and to foster confidence in the clinic services.

• Attend meetings, conferences, workshops, and training sessions and reviews publications and other training materials to become and remain current on principles, practices, and new developments in care coordination.

Education And Experience

• Minimum Qualifications: Bachelor’s degree in Nursing, Social Work, Public Health, or a related field OR equivalent combination of education and experience

• 1-2 years of supervisory or leadership experience

• 3-5 years of experience with population Health, Care Management, care coordination, social work or related healthcare services

Preferred Qualifications

• RN licensure preferred
• care management billing, insurance enrollment, and healthcare coverage programs (e.g., Medicaid, CHIP, Marketplace)
• Experience with population health strategies, risk stratification, registry management, and care management program development
• Experience leading multidisciplinary teams and cross-functional initiatives

Knowledge, Skills, And Abilities

• Knowledge of population health strategies, risk stratification, and care management models within an FQHC setting
• Experience using data and analytics tools (e.g., Azara, Power BI, EHR registries) to drive decision-making
• Understanding of value-based care, quality metrics (UDS/HEDIS), and care management billing requirements
• Proficiency with Microsoft Office and relevant care management/analytics tools (e.g., EHR registries, Power BI)
• Ability to work collaboratively and maintain a positive work environment
• Ability to understand and adhere to required administrative policies and procedures
• Excellent communication skills to ensure efficiencies and quality customer service

Customer Service Excellence

• Doing things right the first time
• Making people feel welcome
• Showing respect for each customer
• Anticipating customer needs and concerns
• Keeping customers informed
• Helping and going the extra mile
• Responding quickly
• Protecting privacy and confidentiality
• Demonstrating proper telephone etiquette
• Taking responsibility for handling complaints
• Being professional
• Taking ownership of your attitude toward Service Excellence

Supervision

• Supervision of care management staff, 11 FTE

Physical Demands And Working Conditions

• Work is mainly performed in a clinic setting.
• Some travel to satellite clinic sites and community outreach events.
• Create and maintain a safe/secure working environment by adhering to safety, security, and health requirements.

Freedom To Act & Decision Making

• Utilizes independent judgment.
• Decisions directly affect the quality of services provided to the public.

Communications & Networking

• Daily written and verbal communication with patients, clients and other staff.
• Work directly with other team members to provide quality customer service for patients and customers.