Brigham and Women’s Hospital Population Health Position

Position Summary:
This innovative program is comprised of a team of centrally based Population
Management Coordinators (PHCs) who are assigned to support a designated Primary
Care practice(s) and are expected to function as integral members of both their central
CPM team and practice based teams.
Using population registries and related data, PMCs work with their assigned practice
teams to ensure that patients receive the condition-specific services they need. For
example, PHCs will: coordinate proactive patient outreach to schedule follow up
appointments, screen/monitor patients using questionnaires regarding mental health or
other conditions, coach patients as they prepare for cancer screening procedures, and
provide reminders about their pre-visit lab tests.
PHCs are also expected to monitor and extract reports from patient registries and share
population level data and outcome measures on a regular basis.

Key areas of responsibility: 

  • Gathers and manages quantitative and qualitative patient data using and EHR population registries and evidenced-based assessment tools
  • Learns and understands Primary Care practice workflows with respect to optimal and coordinated health care for target patient populations
  • Manages patient data collection and generates reports that are convenient for analysis and meet both CPM and practice requirements
  • Conducts timely outreach tailored to meet each patient’s condition specific needs
  • Contributes to Quality Improvement and Process Design of Population Health efforts
  • Works as an effective member of the central (CPM Team) and serves locally as the CPM representative within a practice’s interdisciplinary team
  • Follows established communication protocols and informs clinical team and program leadership accordingly

Principle Duties and Responsibilities

  • Attends and completes PMC orientation within 90 days of start date (unless LOA or alternative plan has been arranged)
  • Attends HR offered “True Colors” Program within 6 months of hire
  • Participates in “Teamness Surveys” (at assigned practice and as a member of the central team)
  • Attends practice and central team meetings as directed
  • Provides regular updates and reports to the Medical Director, Practice Manager and CPM Program Director
  • Creates and manages patient registry reports required to meet the needs of the members of health care teams at assigned practices.
  • Provides data support (when applicable) for practice staff in the development of creative processes to proactively manage target populations
  • Conducts ad hoc analyses as needed for each practice
  • Provides coordination and patient outreach forspecific target patient populations with chronic conditions (or those patients needing cancer screening)
  • Gathers and sorts required data and generate pre-established reports
  • Recognizes and reports data inconsistencies to appropriate personnel
  • Performs all job functions in compliance with applicable federal, state, local and company policies and procedures

Quality Improvement and Process Design

  • Collaborates with care teams to establish population-appropriate pre-visit and point of care processes
  • Works closely with practice teams planning tests of change. Participates in the planning, implementation and analysis of PDSA improvement cycles as appropriate
  • Delivers reports detailing practice level PHS IPF Quality Metrics to practice leaders for distribution
    • Assists in the validation of patient panels (for target populations)
    • Monitors and corrects population registries under the direction of the Provider and the care teams within the practice


  • Bachelor’s degree in social sciences or health management preferred
  • Patient-focused experience or customer service background
  • Working knowledge or familiarity with electronic health records and other health care IT systems desirable
  • Proficient in data management and reporting
  • Proven problem-solver with ability to multi-task
  • Desire to work as part of an interdisciplinary team to improve patients health and wellness 


  • Ability to sensitively engage diverse groups of patients regarding their participation in their healthcare
  • Attend all required training and demonstrate learned skill/content
  • Polished interpersonal skills
  • Comfortable working as member of multidisciplinary, collaborative teams
  • Flexible and able to recognize and adapt to changing circumstances as they arise
  • Think creatively and devise innovative solutions
  • Highly organized, self directed and able to accomplish daily workflows in central office and practice based settings
  • Well developed analytic and writing skills
  • Proficiency in MS Word, Excel, Access and PowerPoint
  • Spanish language fluency strongly desirable
  • Experience with LEAN or other forms of rapid cycle improvement a plus, but not required


  • Office based environment, with periodic travel to ambulatory based primary care practices

Please submit cover letter & resume by Friday 5/5 to Kailee Kennedy)HCC 2018)

Last updated by Janet Umenta May 1.

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