The Population Health Specialist works under the direction of the Chief Quality Officer (CQO) in a dynamic role that promotes patient health, well-being, and appropriate engagement in care. This includes helping patients receive care with virtual visits, supporting incoming calls, and providing daily care coordination and population health activities. The Population Health Specialist works collaboratively with the QI team and clinical teams to ensure compliance with multiple health promotion targets, including those from Patient Centered Primary Care Home (PCPCH), Uniform Data System (UDS), Coordinated Care Organization (CCO), and Oregon Health Authority (OHA). This role supports basic care navigation and care coordination for patients with risk factors such as recent emergency room visits or social determinants of health gaps. The Population Health Specialist may communicate with patients as needed to support coordination of care and appropriate preventive health utilization.


  • Conducts ongoing healthcare gap monitoring and data entry for completion of patient records as required for internal and external reporting
  • Performs chart review using best practice guidelines to evaluate and identify common trends, and gaps in care and documentation
  • Reviews both internal and external healthcare gap reports and works to improve patient outcomes, validate data, and ensure completion of records following reporting requirements
  • Communicates identified opportunities for improvement and staff training needs to the QI team for evaluation of processes, and further review, monitoring, and action
  • Establishes and maintains an organized system to track and analyze outcomes of clinical documentation review
  • Maintains basic knowledge of measure specifications for OHA, CCOs, UDS, HRSA, and PCPCH
  • Performs patient outreach via phone or letter to assist in care coordination, basic care navigation, population health gaps, or other functions. In this role, the Population Health Specialist helps remove barriers to care by providing linkages, identifying resources, and
  • Provides care coordination as directed for patient populations as directed, linking patients to services and supporting patient navigation of care, particularly during times of transition
  • Effectively uses tools available for communicating with the medical or dental care team, through the electronic health record and in verbal communications
  • Providing coverage of department phones
  • Supporting effective utilization of virtual visits through monitoring of the virtual visit platform and working with patients to minimize technology barriers
  • Responsible for data entry into patient charts, as well as payer portals
  • Responsible for effective documenting of care coordination interactions with patients
  • Maintains effective communication with the medical and/or dental care team to support care coordination that promote excellent patient outcomes
  • Supports and assists with QI activities and projects as needed
  • All other duties as assigned.


  • High School diploma required, Associate’s degree preferred
  • Minimum of two years’ experience in a healthcare setting
  • Minimum of two years’ experience working with an Electronic Health Record (EHR)
  • Experience as a Certified Medical Assistant, Certified Nurse Assistant, or other Healthcare role preferred
  • Experience in basic care coordination or case management preferred. · Community Health Worker Certificate or experience in social service organization preferred
  • Experience with data analysis and/or healthcare improvement/process improvement preferred.


  • Excellent communication skills, including the ability to clearly communicate and apply policies and procedures to solve everyday problems and deal with a variety of situations
  • Strong critical thinking and problem solving skills
  • Strong computer skills, working knowledge of Microsoft Word, Excel, and Power Point
  • Skills and experience in working with practice management software preferred
  • Ability and experience to review and analyze data and information and subsequently recommend actions that support clinic goals and objectives
  • Effective customer relations skills, demonstrating the ability to work with diverse groups in a fast-paced environment, displaying an understanding of individual and group dynamics
  • Can demonstrate strong organizational skills and effective use of time. Ability to be self-motivated with limited direction.


  • Sitting at a computer station for long periods of time.


  • Minimal exposure to infectious diseases.


  • 100% office-based.
  • Occasional evening or weekend work required.


  • Computer, printer, calculator, fax machine, copiet, multi-line phone system, private automobile, and/or cellular phone.

To apply, please submit a cover letter along with your resume to