Population Health and Care Integration Manager

JOB SUMMARY

The Population Health and Care Integration Manager will support the Chief Medical Officer in advancing clinical quality, population health performance, care model implementation, Epic/Healthy Planet optimization, documentation review, and cross-site clinical operations. This role serves as an operational extension of the CMO, helping translate clinical priorities into workflows, performance improvement, and consistent execution across sites. The position supports chart audits, daily huddle audits, high-risk huddle preparation, care gap workflows, provider support, clinical technology rollouts, and other operational needs assigned by the CMO.

JOB DUTIES

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required:

• Clinical Operations and CMO Support
• Support the CMO with clinical operations priorities, special projects, meeting preparation, workflow follow-up, and project tracking.
• Serve as a liaison between the Office of the CMO, nurse supervisors, MA supervisors, providers, site leaders, operations, quality/data, and Epic/IT teams.
• Support standardization of care team workflows across sites, including daily huddles, high-risk huddles, care gap workflows, and population health processes.
• Attend selected clinical, operational, and care team meetings to support follow-through on CMO priorities.

Audits, Chart Review, and Documentation Support

• Conduct first-pass chart audits and documentation reviews under the direction of the CMO.
• Review selected charts for documentation completeness, assessment and plan quality, diagnosis specificity, medication follow-up, care gap closure, and alignment with organizational expectations.
• Audit daily huddles, high-risk huddle implementation, care gap workflows, and other clinical operating processes.
• Prepare audit summaries, trend reports, and recommendations for CMO review.
• Identify documentation and workflow trends requiring education, process improvement, or clinical leadership review.

Population Health, Healthy Planet, and Quality Improvement

• Work closely with the VP of Quality and Data to support quality performance, care gap closure, and population health goals.
• Support Epic Healthy Planet, care gap reports, registries, and other population health tools.
• Help care teams interpret patient-level and panel-level quality data.
• Monitor pacing toward quality goals by site, provider, care team, or measure.
• Support MA- and RN-driven quality workflows, including tobacco screening, depression screening, immunizations, cancer screenings, chronic disease measures, and other priorities.
• Develop practical education materials, workflow tools, and tip sheets to improve quality performance.

High-Risk Huddle and Care Model Support

• Perform data deep dives to identify patients for high-risk huddle discussion.
• Prepare patient summaries, care gap information, utilization trends, and relevant clinical context.
• Present or help facilitate patient discussions during high-risk huddles with clinical leadership.
• Track follow-up actions and help ensure care teams close the loop on identified needs.
• Support refinement of high-risk huddle workflows, patient selection criteria, documentation, and site implementation.

Epic, Clinical Workflow, and Technology Rollout Support

• Provide office hours or structured support sessions related to Epic workflows, Healthy Planet, medication refills, lab-order workflows, diagnosis-related documentation questions, and quality workflows.
• Track common workflow questions and identify training or process improvement needs.
• Collaborate with Epic, IT, quality/data, compliance, and operations teams to support workflow optimization.
• Support rollout, adoption, and optimization of ambient dictation and other clinical technology tools.
• Assist with provider onboarding, training logistics, utilization tracking, feedback collection, and workflow support.
• Promote adherence to regulatory requirements and documentation standards.
• Other duties as assigned.

QUALIFICATIONS

Bachelor’s degree in health administration, public health, nursing, health informatics, data analytics, healthcare management, or a related field; equivalent experience may be considered. Master’s degree in health administration, public health, health informatics, data analytics, healthcare management, or a related field preferred.

• Experience in healthcare, preferably primary care, FQHC operations, population health, quality improvement, value-based care, clinical operations, or care model implementation.
• Familiarity with electronic health records and clinical workflows.
• Strong organizational, communication, analytical, and follow-up skills.
• Ability to review data, identify trends, and summarize findings clearly.
• Excellent communication and collaboration skills.
• Experience with Epic, Healthy Planet, or other population health tools.
• Experience with quality measures, care gap closure, UDS, HEDIS, HRSA, payer quality programs, or value-based care initiatives.
• Experience with chart audits, documentation review, clinical quality audits, or provider workflow support.
• Experience with Tableau, Excel, dashboards, registries, or other data reporting tools.
• Experience supporting daily huddles, high-risk huddles, panel management, care team workflows, or clinical technology rollouts.
• Data analysis and reporting
• Workflow design and implementation
• Relationship-building with multidisciplinary teams
• Project tracking and follow-through
• Clear written and verbal communication
• Professional discretion and attention to detail

SMART GOALS (OUTCOMES)

• Partner with Quality and Data teams to monitor performance on key quality measures and support initiatives that improve care gap closure rates by at least 10% in targeted measures.
• Track workflow questions and adoption metrics, providing quarterly recommendations that contribute to increased utilization of Epic and clinical technology tools, including ambient documentation solutions.
• Develop and maintain a centralized project tracker for CMO priorities, ensuring 95% of assigned action items are updated and followed through by agreed deadlines.

PHYSICAL REQUIREMENTS

The physical demands described are representative of those that must be met by an employee to successfully perform. The employee frequently is required to stand, walk, and reach with hands and arms. The employee must occasionally lift and/or move up to 10 pounds.

WORKING CONDITIONS

(The unavoidable, externally imposed conditions under which the work must be performed, and which create hardship for the incumbent including the frequency and duration of occurrence of physical demands, environmental conditions, demands on one’s senses, and mental demands.) None known.

EMPLOYMENT CONDITIONS

This job description is to ensure that essential functions and basic duties have been included. It is intended to provide guidelines for job expectations and the employee’s ability to perform the duties as described. This job description is not intended to be construed as an exhaustive list of all functions, responsibilities, skills, and abilities. Additional functions and requirements may be assigned as deemed appropriate commensurate to the position. This document does not represent a contract of employment, and Friend Health - HRDI reserves the right to change this job description and /or assign tasks deemed as needed.

Friend Health – HRDI is an equal opportunity employer. We consider all applicants for employment without regard to race, religion, color, age, sex, national origin, citizenship, ancestry, marital or parental status, sexual orientation including gender identity, gender expression, military discharge status, physical or mental disability, or any other status or characteristic protected by law. In addition, Friend Health – HRDI provides reasonable accommodations to qualified individuals with disabilities in accordance with the Americans with Disabilities Act and applicable state and local laws (including during the application or hiring process). Friend Health - HRDI supports the Pay Transparency Law as an equal opportunity employer.