New

Population Health Coordinator

Mass General Brigham Community Physicians
United States, Massachusetts, Somerville
399 Revolution Drive (Show on map)
May 01, 2026
The Population Health Coordinator (PHC) is an integral member of a data-driven Ambulatory Quality team that proactively seeks to optimize preventive and chronic disease care. Centrally based PHCs are assigned to support ambulatory practices and are expected to function as innovative and critical members of both their central team and practice-based teams. By gathering and organizing patient data, the Population Health Coordinator works to identify patients' unmet needs, engage patients in their own care, gather summary information for treatment interventions, and enhance ongoing communication between the patient and her/his care team. PHCs facilitate high-value, patient-centered care that improves timely access to and provision of preventive services and chronic disease treatment. Principle Duties and Responsibilities Gathers and manages quantitative and qualitative patient data using population registries and evidenced-based assessment tools Learns and understands Primary Care practice workflows with respect to optimal and coordinated health care for target patient populations Develops a keen understanding of primary care practice requirements Manages patient data collection and generates reports for analysis Conducts timely outreach tailored to meet each patient's condition-specific needs Support PHSO staff to develop creative processes to proactively manage target populations and provide data support and population health education when applicable Provide data management, coordination, and patient outreach as needed for specific target patient populations Recognize and report data inconsistencies to appropriate person Contribute to the teamwork within and between departments. Regularly attend and participate in meetings with coworkers and practice staff. Provide constructive ideas, suggestions, and feedback in a positive manner. Work collaboratively with co-workers to effectively resolve issues that impact departmental or hospital operations Perform all job functions in compliance with applicable federal, state, local and company policies and procedures Attend practice and central team meetings as directed Other duties as assigned Education* High School Diploma or equivalent required, Bachelor's Degree preferred Experience Minimum of 2 years' experience in customer service or in a health care setting. Experience in promoting healthcare behavior change is desirable Knowledge, Skills and Abilities Ability to sensitively engage diverse groups of patients regarding their participation in their healthcare. Flexible and able to recognize and adapt to changing circumstances as they arise. Ability to think creatively and devise innovative solutions. Polished interpersonal skills. Proficiency in medical terminology and HEDIS quality performance knowledge preferred. Prior use of electronic health records and other health care information systems desirable Mass General Brigham Community Physicians, Inc. is an Equal Opportunity Employer. By embracing diverse skills, perspectives and ideas, we choose to lead. All qualified applicants will receive consideration for employment without regard to race, color, religious creed, national origin, sex, age, gender identity, disability, sexual orientation, military service, genetic information, and/or other status protected under law. We will ensure that all individuals with a disability are provided a reasonable accommodation to participate in the job application or interview process, to perform essential job functions, and to receive other benefits and privileges of employment.