Quality & Population Health Specialist

ROLE: This person reports to the Director of Primary Care Integration and bridges data and practice - turning reports and measures into actionable strategies that help improve outcomes, close care gaps, and advance equity through people-centered change management strategies. The Quality and Population Health Specialist is part of the Primary Care Integration team, providing the 'connective tissue' between analytics, education, and operations.

JOB DUTIES:

Data & Analytics

• Pull, validate, and interpret clinical quality data (e.g., UDS, MNCM, payor metrics, etc.).
• Identify trends and care gaps across populations (e.g., diabetes, hypertension, chronic kidney disease, cancer screening, prenatal care, etc.).
• Complete health equity analysis, identifying disparities by demographics or social risk factors.
• Collaborate with Director of Primary Care Integration to ensure data integrity and timely reporting.
• Provide data for grants, QI projects, leadership, and board committees.

Quality Improvement Support

• Support the design, implementation, and tracking of quality improvement initiatives.
• Conduct targeted chart audits to validate data and identify opportunities for improvement.
• Collaborate with Director of Primary Care Integration and work with clinical teams to develop PDSA (Plan-Do-Study-Act) cycles and track progress.
• Monitor progress toward health outcome goals and ensure follow-up.
• Keep up on Electronic Medical Record (EMR) workflows on clinical quality measures and provide appropriate staff education for care standardization and accurate reporting.

Education & Coaching

• Partner with Director of Primary Care Integration and Clinical Directors to develop and deliver trainings for staff and providers on documentation, quality measures, and workflows.
• Translate 'data language' into actionable, psychologically safe clinical and operational insights.
• Using people-centered change management strategies, create quick guides or reference materials to help teams understand how their work impacts metrics.
• Provide feedback in a psychologically safe, trauma-informed, non-punitive way, fostering a learning culture.

Patient & Population Support

• Collaborate with Care Coordinators and Patient Advocates to address social risk factors identified through analytics.

KNOWLEDGE, SKILLS, AND ABILITIES:

• Strong understanding of clinical quality measures and population health concepts, including UDS, MNCM, and value-based care metrics.
• Knowledge of health equity concepts, social risk factors, and strategies for identifying and addressing disparities.
• Working knowledge of Azara for population health analytics, reporting, and care gap identification.
• Experience with OCHIN Epic, including data extraction, registry management, and documentation workflows.
• Ability to collect, clean, analyze, and visualize healthcare data using Excel or similar tools.
• Skilled in quality improvement frameworks and person-centered change management, supporting individuals and teams through process changes (PDSA cycles, root cause analysis, etc.) with empathy and transparency.
• Demonstrates relational leadership and trauma-informed principles - able to build trust, foster collaboration, and engage others in shared improvement goals.
• Strong communication and presentation skills, with the ability to translate data and quality goals into practical, meaningful actions for clinical and non-clinical staff.
• Demonstrated ability to work effectively across disciplines (medical, dental, behavioral health, operations) and with diverse populations.
• Highly organized, self-motivated, and detail-oriented, with the ability to balance multiple priorities and deadlines.
• Committed to equitable, inclusive, and integrated, whole-person care - seeing each metric and report as a reflection of people's lived experiences.
• Embodies Southside's mission, vision, and values in daily work and relationships.

QUALIFICATIONS:

• Minimum of 4 years of experience in quality improvement, population health, data analysis, or healthcare operations.
• At least two years' experience in a healthcare or community health setting.
• Strong analytical and Excel/EMR reporting skills; familiarity with Azara and similar tools a plus.
• Training or certification in quality improvement (e.g., Lean Six Sigma, IHI Open School) a plus.
• Excellent communication and presentation skills; ability to translate data into practical insights.
• Commitment to trauma-informed, inclusive, and equitable care.

WORK ENVIRONMENT AND PHYSICAL DEMANDS:

This position operates in a professional medical clinic/office environment. The role routinely uses standard office equipment. Physical demands include:

• Maintain a stationary position for extended periods while performing essential job duties.
• Must be able to operate typical office equipment such as computers, fax machines, copiers, and telephones, as well as instruments commonly found in a medica clinic (e.g., diagnostic tools, medical devices).

• Requires effective verbal and written communication skills to interact with team members, clients, or patients and to complete necessary documentation.

• Discern test results, x-ray results and distinguish physical cues on patients, such as changes in appearance or condition.

• Must be able to recognize and respond to potential signs of health issues or alcohol impairment through appropriate sensory or observational means.

• Occasional movement throughout the clinic, including moving between different areas to perform essential duties.

• Rarely position oneself to retrieve items or perform certain tasks such as connecting or plugging in equipment.

• Occasionally ascend/descend stairs, ladders to retrieve items.

• May need to move items needed for demonstrations weighing up to 20 lbs short distances.

• This position may require regular interaction with individuals who have communicable illnesses, which may pose a risk of exposure to infectious diseases.

Reasonable accommodation can be made for qualified individuals with disabilities to enable them to perform the essential functions of the role.