Population Health Manager

Posted: 06/30/2022

Apply Here: https://recruiting.paylocity.com/recruiting/jobs/Details/1167232/Fenway-Health/Population-Health-Manager

Population Health Initiatives at Fenway Health are aimed at proactively managing health center patient populations with chronic conditions (e.g. diabetes, hypertension, depression) and those in need of preventive services, and ensuring delivery of evidence based care through a team-based, patient centered medical home (PCMH) model of care. 

Fenway Health is a member of two Accountable Care Organizations (ACOs): the Community Care Cooperative (C3) which serves the Mass Health (Medicaid) population, and the Beth Israel Lahey Health Performance Network (BILPN), serving commercial and Medicare populations. As a member of these ACOs, Fenway Health takes responsibility for managing the quality and cost of care for the ACO’s associated enrollees. In addition, as a Federally Qualified Community Health Center, recognized by the National Committee for Quality Assurance as a Patient Centered Medical Home (PCMH), Fenway aims to reduce health care disparities and deliver evidence based quality chronic disease and preventive health care to its entire population served.  


Under the direction of the Director of Quality Improvement, the Population Health Manager (PHM) works to achieve optimal performance within value and risk based care initiatives by leading practice staff in the development and implementation of quality improvement activities to close population health care gaps and achieve quality performance goals. 

  1. Actively works to identify and implement opportunities for improvement in clinic workflows to improve population health:
  • Partnering closely with health center leadership, providers, and staff, the PHM plays a crucial role in performance improvement by identifying gaps and root cause operational issues, both through data and operational observation, by providing feedback and education, and by recommending actionable initiatives from the opportunities identified.  
  • Leads practice staff in integrating the goals of value and risk based contracts into the Patient Centered Medical Home (PCMH) model of care. Contributes to the teamwork within and between departments and roles. Provides constructive ideas, suggestions, and feedback in a positive manner. Works collaboratively with co-workers to effectively resolve issues that impact health center operations. 
  • Utilizes the health center’s Electronic Medical Record (EMR) and available population health registries (Arcadia, Care Manager) to manage patient data, generate practice reports, and to identify opportunities to improve both clinic workflows and data quality accuracy 
  • Measures and documents the outcome of improvement activities undertaken by practice staff to improve population health outcomes 
  • Shares outcomes, including successes, challenges, and resolutions related to process improvement between ACO and Health Center staff, and helps disseminate best practices. 
  • Lead and participate in population health/ Quality Improvement work groups.  
  • Answer and/or research questions on problems clinic staff have identified. 
  • Recognizing and reporting data inconsistencies to appropriate Health Center and ACO staff. 
  • Manages relationships with outside vendors and agencies that support population health functions. 

2. Leads activities to achieve quality performance goals and to close care gaps by:

  • Serves as a subject matter expert on quality measure specifications within value based care contracts and UDS clinical quality measures.  
  • Ensures the optimized use of population health registries (Arcadia, Care Manager) and the EMR to generate and deliver population health outreach reminders (i.e. via email, letters, telephone outreach)
  • Utilize Quality performance data to plan outreach strategies 
  • Leads teams in designing, implementing and improving workflows in support of patient centered, team based care.   
  • Leads efforts to disseminate quality performance information to medical teams/ practice staff and to solicit input and engagement from staff in QI activities. 
  • Gathering data and records available outside of the practice to ensure comprehensive population health data is retained in the Fenway EMR. 
  • Providing patient-level data records, as appropriate, to ACO staff, including data entry for care gaps and complete coding. 
  • Supports annual HEDIS Audit data reporting to payers, as appropriate 

3. NCQA - PCMH Annual Application Coordination and Submission

  • Responsible for annual submissions to NCQA to ensure maintenance of Patient Centered Medical Home Recognition and Distinction in Integrated Behavioral Health
  • Learns and maintains expert level knowledge of the NCQA PCMH recognition requirements, including annual updates, and documents accordingly within the NCQA Q-Pass system. 

4. Performance report preparation and dissemination, including:

  • Synthesizing, sorting, formatting data, and generating ad-hoc reports from population health registries
  • Reviewing C3 and BILPN risk contract quality and cost performance reports with practice staff and making recommendations for improvement 
  • Reviewing overall practice performance reports with practice staff Reviewing patient non-compliance and gap reports with primary care teams
  • Preparing and submitting required reports to C3 Oversight staff 
  • Developing and presenting progress, chart audit, exceptions and exclusions reports to BILPN staff 

5. C3 Community Partners (CP) Coordination

  • Manages Fenway’s CP program including collaboration with External CP staff 
  • Integrate care between Health Center/PCP/Community Partners and patient
  • Facilitate process of signing Care Plan by PCP/PCP Designee, and returning to Community Partners
  • Facilitate relationship building and workflow improvement with Community Partners
  • Place referrals for patients for CP services, as needed

6. Actively serves as a content expert in ACO Quality and Risk based initiatives for Population Health

  • Leads health center’s Patient Centered Medical Home team meetings
  • Participates in weekly BILPN and C3 meetings held at the health center 
  • Participates in C3 Population Health management related meetings 
  • Attends ACO related trainings and disseminates relevant information and training to practice staff, including: 
  • C3 programmatic and Arcadia platform trainings
  • BILPN -Arcadia trainings
  • Leads C3 complete coding initiatives to ensure accurate capture of acuity. 
  • Trains staff including providers and BH clinicians on Complete Coding
  • Provides ongoing staff training as needed related to ACO initiatives and quality improvement and continuous improvement concepts 

7. Meets Agency Participatory Expectation

  • Adheres to all agency and departmental policies and procedures
  • Upholds the principles of customer service in all interactions with all co-workers, patients, and external stakeholders
  • Participates in additional quality assessment and improvement activities as requested
  • Adheres to the highest principles of patient and client confidentiality
  • Adheres to established safety policies, procedures and precautions; identifies potential or actual unsafe situations in the environment and informs appropriate staff
  • Attends all required meetings, in-services and professional trainings
  • Maintains professional competence necessary to perform job responsibilities; maintains and provides agency with records of continuing education activities

8. Other Responsibilities:

  • Provides ongoing management and supervision of Population Health Coordinator(s)
  • Performs related duties as required 


  • Bachelor’s degree required, master’s degree in a relevant field preferred. May be substituted with 5 years of relevant experience in Quality Improvement and Population Health. 
  • Minimum 3-5 years of relevant experience in healthcare, continuous improvement and/or Population Health and value based care  
  • Demonstrated experience leading multidisciplinary teams or projects
  • Demonstrated proficiency in data management, analytics, and reporting required
  • Well-developed analytic and writing skills required
  • Ability to work harmoniously and effectively with colleagues, patients, clients and vendors across the spectrum of diversity, including but not limited to race, ethnicity, color, gender identity, sexual orientation, age, socio-economic status, national origin and immigrant status, religious or spiritual identity, disability (physical, mental, emotional and developmental), veteran status, and/or limited English proficiency.
  • Willingness to contribute towards Fenway’s efforts in becoming an anti-racist organization and promoting a culture dedicated to ongoing development in service of humility, equity, diversity, inclusion, and belonging, where differences are acknowledged and valued.
  • Proficient in MS Word, Excel, and PowerPoint. 

Preferred Qualifications:

  • Working knowledge or familiarity with electronic health records and other health care IT systems strongly preferred 
  • Highly organized and self-motivated individual with the ability to work autonomously 
  • Collaborative working style with the ability to work with staff across different departments, teams, and roles. 
  • Proven problem solver with ability to manage multiple priorities required
  • Experience, education, and/or training in Lean, Toyota Production System, or other forms of rapid cycle continuous improvement preferred 
  • Working knowledge of clinical quality metrics such as HEDIS NCQA or National Quality Forum type metrics desirable 
  • Supervisory experience, preferred
  • Patient-focused experience or customer service background preferred
  • Experience in promoting health behavior change, preferred 

We offer competitive salaries, and for those who qualify, an excellent benefits package; including comprehensive medical and dental insurance plans, and a retirement plan with employer match. We also provide 12 paid holidays, paid vacation, and more. LGBTQIA+ identified persons, Black, Indigenous, and other people of color (BIPOC), and individuals from other historically underrepresented communities are strongly encouraged to apply.