Medical Assistant jobs at Meridian HealthCare

The Population Health Assistant supports Meridian HealthCare's mission of providing integrated, whole-person care by advancing initiatives that improve clinical outcomes, reduce health disparities, and enhance care coordination across our Federally Qualified Health Center (FQHC) Look-Alike service lines. This position plays a key role in identifying and engaging at-risk patients, closing care gaps, and supporting value-based care performance through data analysis, quality improvement, and collaboration with interdisciplinary teams. Key Responsibilities Utilize population health and EHR reporting tools to identify high-risk patients, monitor health outcomes, and track key quality metrics such as HEDIS, UDS, and other value-based indicators. Coordinate proactive outreach to patients for preventive care, chronic disease management, and follow-up after hospital or emergency department visits. Collaborate with primary care, behavioral health, case management, and recovery support teams to ensure coordinated, patient-centered care. Monitor and assist with Social Determinants of Health (SDOH) screenings, ensuring patients are connected with community resources and support services. Participate in quality improvement initiatives that strengthen clinical workflows, reduce care gaps, and align with HRSA and NCQA PCMH standards. Generate and analyze reports on clinical outcomes, patient engagement, and program effectiveness; assist with preparing data for HRSA and other grant or funding reports. Support implementation of care coordination protocols, chronic disease registries, and performance dashboards to improve population health outcomes. Conduct patient education and outreach to promote preventive health behaviors, treatment adherence, and participation in wellness programs. Provide training and technical assistance to staff regarding documentation, quality metrics, and care coordination workflows. Serve as a liaison between clinical teams and leadership to communicate trends, barriers, and opportunities for improvement. Requirements Qualifications Minimum of two years of experience in population health, care coordination, or quality improvement within an FQHC, primary care, or behavioral health setting. Knowledge of FQHC quality measures, UDS reporting, and value-based payment models. Familiarity with social determinants of health frameworks and resource referral systems. Proficiency in EHR systems (NextGen preferred), data dashboards, Microsoft Excel, and reporting tools. Strong analytical, organizational, and communication skills, with the ability to collaborate effectively across multiple disciplines.