Population Health Manager

JOB DESCRIPTION Title: Population Health Manager FLSA Category: Exempt Reports To: Director of Quality and Clinical Management Greater Baden Medical Services (GBMS) is a Federally Qualified Health Center (FQHC) dedicated to providing high-quality healthcare across Southern Maryland. With 9 clinical sites across Prince George's, Charles, and St.

Mary's counties, we serve over 18,000 patients each year. We provide fully integrated care that includes primary care, pediatrics, women's health, Title X family planning, dental care, behavioral health, WIC, pharmacy services, and the Ryan White HIV/AIDS program. Our patient population is primarily made up of Medicaid and uninsured individuals.

We are deeply proud to deliver these vital services to everyone in our community, regardless of their ability to pay, making Greater Baden an incredibly rewarding place to grow your career while making a tangible, life-changing impact every day.

Job Summary

The Population Health Manager leads population health initiatives, oversees clinical and community outreach strategies, and monitors Managed Care Organization (MCO) engagement with GBMS. Utilizing data insights from CRISP (Chesapeake Regional Information System for our Patients) and quality metrics, this role directs disease management programs, monitors socioeconomic drivers of health (including redeterminations), and directly manages the population health team to improve health outcomes and reduce health disparities.

Essential Functions

Direct Supervision & Management: Directly supervises, mentors, and manages the daily workflows of the Population Health Team CRISP Data: Leverages CRISP health information exchange platforms (inpatient/ED notifications, prompt discharge alerts, panel processors, and multi-payer reporting) to drive care coordination, fulfill Maryland AHEAD Model quality and population health objectives, and ensure timely follow-up appointments, patient education.

Staff Training & Professional Development: Provides ongoing training and guidance to staff regarding member health education, preventative care navigation, and health literacy strategies. HEDIS & Quality Metrics Oversight: Oversees statistical data and reporting related to HEDIS, Value-Based Care (VBC), Gaps in Care, and No-Encounter reports to drive targeted outreach and program improvements.

Quality & Diversion Initiatives: Actively participates in Patient-Centered Medical Home (PCMH) frameworks, Emergency Department diversion projects, and quality improvement (QI) initiatives aimed at improving proper utilization and reducing hospital readmissions. Incentive Program Administration: Monitors and administers member incentive programs designed to encourage annual preventative visits and support HEDIS compliance measures.

Disease & High-Risk Management: Manages disease management workflows for patients with co-morbidities and oversees high-risk care coordination in collaboration with the clinical team. Health Education & Promotion: Develops, implements, and evaluates targeted health education and promotion programs (e.g., Diabetes, Asthma, Prenatal/Postpartum, and Dental Health) to enhance member health literacy and health outcomes.

Transitions of Care Coordination: Collaborates closely with clinic and hospital staff to ensure patients discharged from emergency departments, urgent care centers, or inpatient stays receive post-discharge follow-up appointments and telephonic instruction. MCO Liaison & Engagement: Serves as the primary liaison with Managed Care Organizations (MCOs) to align initiatives, track MCO engagement, and advance the agency’s mission.

Community Outreach Strategy: Drafts and oversee the schedule for community engagement, health literacy events, and outreach opportunities in partnership with MCOs and local community partners. SDOH & Disparity Reduction: Assesses socioeconomic factors and social determinants of health (SDOH) to identify and eliminate access barriers, reducing health disparities across the served population.

Nonessential Functions: Provides support for special clinical initiatives, such as designated screening/clinic days and those required by assigned grant and special programs. Provides staff training on health education to members about the importance of preventative visits. Completes other projects and duties as assigned by supervisor Managerial Responsibilities:

1. Yes- Population Health Team Minimum Qualifications: Bachelor’s degree in Bachelor of Science in Nursing (BSN) OR Bachelor’s Degree in Public Health, Health Administration, or a closely related field required. 3+ years of experience in population health, care coordination, public health, or outpatient clinic settings. 1+ years of supervisory or team lead experience managing clinical or community outreach staff. Licensure/Certification: Active RN License required if applying with a BSN.

Preferred Qualifications

Hands-on proficiency with CRISP (Maryland Health Information Exchange) tools and dashboards. Working knowledge of the HEDIS, Value-Based Care (VBP), and EHR platforms. Core Competencies Needed Accountability – Meets established expectations and takes responsibility for achieving results; encourages others to do the same.

Collaboration – Engages others by gathering multiple views and being open to diverse perspectives, focusing on a shared purpose that puts the organization overall success first. Communication – Listen and verbally to solve problems and provide information and direction, ensuring the experience is a positive one. Record issues and resolutions to maintain accurate records and data for further analysis by management.

Quality Improvement – Ensures customer satisfaction, provides training, develops, and implement performance and process improvement initiatives. Organization – Effectively managing tasks and information and organize information to ensure a timely response to questions. Develops and uses systems to organize and keep track of information or work progress.

Work Environment This job operates in a professional office environment. This role routinely uses standard office equipment such as computers, phones, photocopiers, filing cabinets and fax machines Work Arrangement This is a hybrid position requiring a combination of on-site and remote work. Employees are expected to work on-site in accordance with departmental scheduling and operational needs.

Physical and Mental Demands Ability to remain in a stationary position 50% of the time. Ability to cope with stress. Constantly operates a computer and other office productivity machinery, such as a calculator, copy machine and computer printer. The person in this position frequently communicates with patients and/or employees.

Must be able to summarize and exchange accurate information. Performs a variety of duties, often changing from one task to another. Performs with frequent interruption or distractions. Adjust priorities quickly as circumstances dictate. Ability to interact appropriately with colleagues for different purposes in different context.

Expressing or exchanging information to convey detailed spoken instructions accurately, or quickly. Ability to judge distances and spatial relationships to see objects where and as they actually are. Cognitive ability to analyze, count, summarize and synthesize information from multiple sources. Language Skills Ability to read and interpret written or verbal documents and instructions.

Ability to speak effectively to patients, employees and/or stakeholders of the organization. Compliance This position requires compliance with Greater Baden Medical Services (Health Center’s) compliance standards, including its Standards of Conduct, Compliance Program, and policies and procedures. Such compliance will be an element considered as part of the Population Health Manager regular performance evaluation.

Travel Must be able to drive between Greater Baden Medical Services, Inc. locations.