Population Health Coordinator

Henrietta Johnson Medical Center (HJMC) is a Federally Qualified Health Center with sites in Wilmington and Claymont, Delaware, providing an all-inclusive range of medical and dental services for the entire family. HJMC provides affordable access to integrated and coordinated family practice, women's health, dental, and behavioral health care services under one roof, with a team of caring, competent, and productive providers and staff focused on quality, compassionate, and coordinated care.

The Population Health Coordinator supports value-based care through registry management, quality analytics, patient outreach, and care coordination strategies that identify and close gaps in care. This role improves preventive care and chronic disease outcomes, strengthens contract performance, and reduces avoidable costs through proactive population-level interventions.

• Maintains and works on assigned registries, dashboards, and reports to identify patients due for preventive, chronic care, and transitional care services.
• Conducts outreach to engage patients with overdue screenings, immunizations, chronic disease follow-up, and other quality measures tied to payer and regulatory requirements.
• Partners with clinical, front-desk, referral, and care management teams to close care gaps and support high-risk patient interventions.
• Assists with data validation, reconciliation, and documentation workflow improvement to support accurate quality performance and reporting.
• Prepares and shares actionable worklists, panel insights, and performance trends with operational and clinical leaders.
• Coordinates referrals, diagnostic follow-up, and tracking processes that support continuity of care and reduce leakage.
  
  Supports UDS, value-based contract measures, quality improvement projects, and clinical transformation initiatives.
• Maintains compliance with HIPAA, organizational policies, and minimum-necessary access principles in all data handling activities.

• Bachelor's degree in public health, health administration, nursing, data analytics, or a related field; equivalent relevant experience may be considered.
• Two years of experience in population health, care coordination, quality improvement, managed care, or healthcare analytics.
• Experience working with electronic health records, registries, reporting tools, and patient outreach workflows.
• Strong organizational, communication, and analytical skills.

• Experience in an FQHC, primary care practice, or value-based payment environment.
• Experience with eClinical
  
  Works, Azara DRVS, or another population health platform.
• Working knowledge of UDS, HEDIS-like measures, and panel management concepts.

This position is funded through Delaware's federal Rural Health Transformation Program grant, awarded through the Delaware Department of Health and Social Services. Although the RHT award covers a five-year project period, funding is approved and allocated annually, and continued employment in this role is contingent on annual grant reapproval.

This role offers a competitive salary based on experience and community health center pay standards in Delaware. Employees enjoy a range of benefits, including:

• Health Insurance (Medical / Dental / Vision)
• Long-Term Disability
• Employee Assistance Program (EAP)
• Short-Term Disability Option

Henrietta Johnson Medical Center is an equal opportunity employer.

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