The Opportunity

The Population Health Specialist supports Akido’s value-based care strategy by identifying, engaging, and coordinating care for patient populations requiring preventive services, chronic disease management, and care gap closure. This role collaborates with providers, clinic teams, health plans, and patients to improve quality outcomes, patient engagement, continuity of care, and access to services.

The Population Health Specialist utilizes population health tools, patient registries, quality reports, and outreach workflows to support HEDIS, STAR, risk adjustment, Annual Wellness Visits, and other quality initiatives while contributing to organizational performance and patient health outcomes.

What you'll do

Essential Functions

Conduct patient outreach and engagement activities to close preventive and chronic care gaps.
Coordinate appointments, screenings, referrals, and follow-up services.
Support organizational quality improvement and value-based care initiatives.
Maintain accurate patient documentation and outreach records.
Collaborate with interdisciplinary teams to address barriers to care.
Monitor and track performance metrics related to population health outcomes.
Support patient retention, engagement, and continuity of care efforts.

Key Responsibilities

Population Health & Care Gap Management

Identify patients with open quality, preventive, and chronic care gaps through approved reports, registries, and work queues.
Conduct outreach through phone calls, text messaging, patient portals, and other approved communication channels.
Coordinate Annual Wellness Visits, preventive screenings, immunizations, specialty referrals, chronic disease follow-up, and diagnostic testing.
Document outreach efforts, patient responses, barriers, and intervention outcomes accurately and timely.
Prioritize patient outreach based on clinical risk, health plan requirements, and organizational goals.

Patient Engagement & Care Coordination

Serve as a primary point of contact for assigned patient populations.
Educate patients on preventive care recommendations and available healthcare resources within scope of practice.
Collaborate with clinical and operational teams to address barriers impacting care completion.
Escalate clinical concerns and complex patient needs to the appropriate licensed team members.

Quality & Value-Based Care Support

Support HEDIS, STAR, risk adjustment, Medicare Advantage, Medi-Cal, and other value-based care initiatives.
Review quality reports and assigned patient lists to identify intervention opportunities.
Assist with chart review, data validation, documentation improvement, and quality audits.
Monitor progress toward care gap closure and quality performance goals.
Follow standardized workflows to ensure accurate quality reporting and compliance.
Attend IPA and health plan meetings where our performance is reviewed, and own follow-up on every commitment made.

Data Management & Reporting

Maintain accurate records within the electronic health record (EHR) and population health platforms.
Track outreach volume, completion rates, and unresolved patient barriers.
Prepare routine reports and communicate trends, risks, and workflow issues to leadership.
Produce clinician-level performance reports and lead provider and staff education with the Medical Director.
Maintain confidentiality and comply with HIPAA, privacy, and security regulations.

Collaboration & Continuous Improvement

Work collaboratively with physicians, advanced practice providers, nurses, medical assistants, referral coordinators, and clinic operations teams.
Participate in team meetings, quality reviews, and process improvement initiatives.
Support implementation of new population health programs and workflow enhancements.
Perform other duties as assigned.

Who you are

Required Qualifications

Five or more years of quality or value-based care experience in a medical group, IPA, MSO, health plan, or ACO.
Experience utilizing EHR/EMR systems and Microsoft Office applications.
Strong communication, customer service, organizational, and problem-solving skills.