Population Health Specialist
Milwaukee, WI 
Posted 17 days ago
Job Description
Join our team who is committed to the delivery of the highest quality health care service. We are seeking a full-time Population Health Specialist that is self-motivated, energetic, and a take charge individual. The Population Health Specialist utilizes information from several sources, both internal and external to the organization, to identify gaps in patient care aligned with Value Based Care programs and performs patient outreach to support closure of those gaps. We are willing to train the right candidate.

Job Responsibilities:
  • Pull data and reports from multiple databases/portals and electronic health records to identify potential care gaps and follow the appropriate process to close those gap(s).
  • Work collaboratively with appropriate care teams to notify teams of missing documentation or to obtain documentation to close identified care gaps.
  • Perform outreach to patients in accordance with organizational policies and procedures to schedule follow-up appointments, conduct screenings or obtain patient reported documentation to facilitate closure of identified care gaps.
  • Work with payors to understand individual program requirements to close gaps and follow established processes within HIPAA regulation compliance.
  • Ensure accuracy and timeliness in submission of records to payers.
  • Develop workflows and processes to attain targets established by the organization and value-based contracts.
  • Under the guidance of the Director, provides reports to leadership and various committee in a concise clear manner.
  • Schedule and coordinate follow-up visits for patients following hospitalizations to ensure medication reconciliation occurs timely, provide patient education in clear, professional manner and in a manner that is understandable to patient and/or family.
  1. High School Diploma or General Equivalency Degree, minimum.  Associates Degree in a health care related field, preferred
  2. Medical Assistant experience or other health care experience preferably in a health education field
  3. Excellent oral and written communication skills
  4. Strong computer and typing skills, working knowledge of EHRs and Microsoft Office products
  5. Must demonstrate strong critical thinking and problem-solving skills
  6. Works autonomously and be accountable in a complex environment
  7. Ability to relate to people from diverse ethnic and cultural backgrounds
  8. Bilingual Spanish/English required
  9. Motivational Interviewing experience preferred but not required at time of start.  Will be required to maintain once onboard
  10. Knowledge of ACO, HEDIS, CMS and other quality measures preferred


Contact Information
No Phone Calls Please. Qualified applicants may send resume to Sue Raymond, Vice President of Human Resources, Sixteenth Street Community Health Center, 1337 S. 16th St., Milwaukee, WI 53204 or fax to 414-672-0413.Sixteenth Street Community Health Centers is an equal employment opportunity employer.
Job Summary
Start Date
Employment Term and Type
Regular, Full Time
Hours per Week
Work Hours (i.e. shift)
1st Shift
Required Education
High School or Equivalent
Required Experience
1+ years
Email this Job to Yourself or a Friend
Indicates required fields