Population Health Project Coordinator

ST. BARNABAS HOSPITAL
BRONX, NEW YORK

JOB DESCRIPTION/PERFORMANCE EVALUATION

DEPARTMENT: Population Health, Ambulatory Care

POSITION TITLE: Population Health Project Coordinator

REPORTS TO: Director

DATE REVISED: September 29, 2025

PRINCIPAL MISSION:
The Population Health Coordinator works directly with patients on population health programs to improve patient care. The coordinator also implements clinical data activities, and performance improvement and population health activities across Ambulatory Care, Emergency Department and Inpatient settings. They collaborate with stakeholders to gather data, run analytic reports, and interact directly with patients to improve their health. This includes meeting patients to discuss specific program goals, reviewing patient charts to identify gaps in care, and completing patient text message and telephone campaigns.

PRINCIPAL DUTIES AND RESPONSIBILITIES:

• Promote a safe, cooperative and professional health care environment to ensure optimum patient care (as per HR Policy 113c).
• Adheres to all hospital policies, procedures, rules and regulations, including but not limited to, absenteeism, ETIME, cellular telephone usage, dress code and rules of conduct.
• Makes Customer Service a priority, treating customers (patients, visitors, and co-workers) in a professional manner exercising courtesy and tact. Effectively communicates with patients and others about SBH services in their area(s) of expertise or responsibility and ensures that concerns, questions or issues reach the right person(s) in SBH in a timely fashion.
• Demonstrates the standards of performance and behaviors consistent with the DRIVE to Patient-Centered Excellence.
• Implement population health programs as assigned, including, but not limited to:
  • The Prescription Helper program, sending targeted text message reminders and phone calls to patients who are overdue for refills, and providing assistance to patients enrolled for enhanced support.
  • The Recertification program, sending targeted text message reminders and phone calls to patients who need to renew their Medicaid coverage, providing direct support to patients in completing the online recertification process.
  • The Pathfinder program, providing direct care transitions support and treatment linkage to patients with mental health or substance use issues.
  • The Living Positive program providing direct support to patients with Viral Load suppression and our Undetectables initiative.
• Collaborate with leadership, practice management, IT, and other stakeholders to collect and process data to improve the quality of clinical care.
• Produce and distribute chase list reports to clinical and patient-facing teams to guide patient care and improve care quality and performance.
• Review electronic medical records to confirm if patients are missing services or are navigating a transition in their care.
• Support quality improvement projects in Population Health and Ambulatory Care services, and take responsibility for agreed actions.
• Contribute to presentations, diagrams, and flowcharts for clinical staff.
• Perform other duties at the discretion of leadership.
• Attend scheduled department and division meetings and participate as appropriate.

The above statements reflect the general duties considered necessary to describe the principal functions of the job as identified, and shall not be considered as a detailed description of all work requirements that may be inherent in the job.

QUALIFICATIONS:

• Associates Degree required, Bachelor's Degree preferred.
• Two (2) years' experience in healthcare quality settings with data or statistical analysis, data manipulation, and reporting is preferred.
• Experience working with patients with mental health or substance use issues preferred.
• Candidates must have good skills with Microsoft Excel, and have a basic knowledge of vlookup, pivot tables and formulas.
• Excellent written and oral communication skills
• Attention to detail and accuracy
• Excellent organizational skills