Come make a difference in the lives of people every day while helping us achieve our mission: To improve the health of our patients and communities by delivering exceptional care, removing barriers, and promoting healthy lifestyles.

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.

Population Health jobs

Quality & Population Health Specialist