Population Health Coordinator - Medical Focus

Accountabilities:

• • Maintain accurate member registries for specialized populations and care pathways, using data to track outcomes, assess progress, prioritize work, and support care-team decision-making.
  • Facilitate regular registry reviews with counselors, medical providers, consulting specialists, and other interdisciplinary team members.
  • Participate in caseload consultations and communicate treatment recommendations and care priorities to appropriate members of the care team.
  • Analyze population-level data and care outcomes to identify opportunities for quality improvement and recommend initiatives that enhance care delivery.
  • Perform and document internal and external care coordination activities for members with complex medical needs or challenging care scenarios.
  • Support local care teams in applying the Collaborative Care Model and assist with training on registry reviews, asynchronous consultations, concise clinical presentations, and related workflows.
  • Manage an assigned member caseload through telephone, SMS, and individual telemedicine interactions, providing screenings, structured assessments, brief interventions, and care coordination.
  • Educate members about common physical health, mental health, and substance-use conditions, available treatment options, and strategies for navigating their care.
  • Provide transitional care support to high-acuity members entering or progressing through recovery, including interdisciplinary meetings, orientation groups, care coordination, and individual support.
  • Facilitate and document treatment-plan updates in collaboration with medical and clinical providers.
  • Identify and escalate urgent or crisis situations to appropriate clinical or medical leadership and support follow-up and safety-planning activities.
  • Support pilot projects by providing administrative, technical, analytical, and leadership assistance as delegated by medical, clinical, and operational leaders.
  • For the Medical Focus, support medication management activities by monitoring adherence, side effects, and treatment effectiveness in accordance with provider direction.
  • Help develop and deliver accessible, low-barrier, culturally appropriate educational materials covering addiction medicine, primary care, and other relevant medical topics.
  • Review medical information and prepare documentation that enables medical colleagues to practice efficiently at the appropriate level of clinical expertise.
  • Support medical-related care coordination and contribute across other population focus areas when needed to ensure comprehensive member support.

  Requirements:

  • Current Registered Nurse (RN) license, or, in Maine only, Licensed Practical Nurse (LPN) who completes the required SAMHSA training for an X-DEA license.
  • Bachelor's degree in Nursing is preferred.
  • At least 5 years of direct patient-care experience in addiction medicine, behavioral health, or a related clinical setting within a high-quality healthcare organization.
  • Strong understanding of care coordination, case management, population health, and interdisciplinary care delivery.
  • Knowledge of healthcare regulations, HIPAA requirements, and professional standards of conduct.
  • Strong ability to communicate clearly and effectively with dispersed internal teams, external providers, and diverse member populations.
  • Comfortable facilitating communication across telehealth, virtual platforms, telephone, and in-person care settings.
  • Strong data-analysis skills, including the ability to interpret registries, outcomes, and other population health information to support care decisions.
  • Excellent organizational and documentation skills, with the ability to manage multiple priorities accurately and efficiently.
  • Proficiency with multiple electronic medical records, Microsoft Office or Google Workspace, spreadsheets, and other digital documentation tools.
  • Strong problem-solving and decision-making capabilities, particularly when navigating complex or evolving care situations.
  • Ability to build trust and rapport with diverse patient populations while maintaining appropriate professional boundaries.
  • Demonstrated discretion, independence, adaptability, and the ability to work effectively under general supervision.
  • Willingness to obtain additional training and adjust working hours within the normal work week when needed to accommodate member care.
  • For remote work, reliable internet and telephone service are required, with recommended minimum speeds of 50 Mbps download and 10 Mbps upload and a strong Wi-Fi signal.
  • Ability to meet and maintain applicable background-screening, credentialing, licensing, health-screening, CPR/Basic First Aid, and other state- or role-specific requirements.

  Benefits:

  • Competitive annual salary of $75,000–$90,000.
  • Monday–Friday schedule, generally 8:00 AM–5:00 PM EST.
  • Opportunity to contribute to innovative population health and Collaborative Care Model initiatives.
  • Meaningful direct impact on high-acuity and medically complex member populations.
  • Collaborative environment working alongside medical providers, counselors, specialists, peer support, and care-navigation professionals.
  • Opportunities to contribute to pilot programs and continuous improvement initiatives.
  • Professional development and additional training opportunities.
  • Opportunity to work across interdisciplinary care settings and specialized population health programs.