Population Health Specialist

Who We AreAt Suvida Healthcare, we are not just caregivers; we're compassionate advocates dedicated to enriching the lives of our cherished seniors. As a Team Member with us, you will embark on a fulfilling journey where your skills and empathy converge to make a meaningful impact on the well-being of an underserved community and their families. Our multi-disciplinary primary care program is built to address the physical, behavioral, social, and cultural needs of Medicare-eligible Hispanic seniors. Celebrate diversity and inclusivity in a workplace that attracts, engages, values, rewards, and recognizes the unique needs and backgrounds of both, our patients and our team. We believe that a rich tapestry of experiences, shared interests, and perspectives enhances the care we provide, making us a stronger, service-centered, and more compassionate healthcare family and Employer of Choice! Will you join us Suvidanos, to help achieve our Higher Purpose?What Makes Us UniqueWe are an empowered primary care team, clinical operations, and support team creating health equity through an exceptional clinical and consumer experience that improves the quality of life for the people, families, and neighborhoods we serve. We tailor our primary care program to the culture, language, social, and overall well-being of the seniors we serve. How We WorkOur Culture & Core BeliefsEarn TrustBuilding RelationshipsCreating JoyDoing RightImproving Every DayMoving ForwardOur PromisePurpose Driven CareerCompetitive PayBest-In-Class Medical/Dental Coverage Free Mental Health & Life Coaching for Team Members and their DependentsHoliday Time Off with PayPaid Community Service DayPaid Parental/Family LeavePaid Bereavement LeaveGenerous Paid Time Off (PTO)401k Retirement Plan with Company MatchAnd much more....What You'll Do Position SummaryThe Population Health Specialist will play a critical role in managing patients with uncontrolled diabetes and hypertension. This individual will focus on supporting the clinical staff and patients through longitudinal management of patients and reinforcement of their care plans by various clinical teams - Primary care providers, pharmacists, nutritionists, etc. The COS will communicate with and coordinate between patients, clinical staff, and pharmacies daily to ensure visits, orders/labs, and medication changes flow smoothly and troubleshoot barriers as they occur.ResponsibilitiesManage a population of targeted diabetic and hypertensive patients using Suvida's platforms and EMR.Conduct telephonic outreach to patients, coordinate care, and facilitate engagement, with occasional in-person clinic visits as needed.Schedule and coordinate lab draws, A1C kits, and CGM downloads - collaborating with clinic staff and following clinic-specific procedures.Support medication adherence, motivational interviewing, and patient education, including basic nutrition coachingAs needed, schedule and perform phlebotomy/venipuncture & vitals for in-person visitsAs needed, schedule and perform in-home visitsAs needed, perform other duties as assigned Collaborate with PCPs and Clinical Pharmacists and help patients (and their caretakers/family members) manage their care plans and escalating issues appropriately and timely.Document all patient interactions and care coordination in the EMR. Maintains education and basic knowledge of HEDIS/STARs measures]Maintains education and knowledge base of refills and prior authorization workflows Maintains understanding of current Suvida's clinical programs, events, and classes designed around Diabetes and HypertensionEnsure patients have a positive experience by providing a high level of service promptly, professionally, and empatheticallyDemonstrated ability to work independently, solve problems, and make sound decisions in a timely fashionPossess both verbal and written communication skills, interpersonal relationship skills and problem-solving skillsWhat You'll BringKnowledge, Skills, and AbilitiesMinimum 3 years Previous Medical Assistant experience 5 years medical assisting experience preferred Advanced in Microsoft office platforms including word, excel, and power pointBilingual/Bicultural (English and Spanish)Education, Experience, Licensure, or Certification Requirements High School Diploma or equivalent requiredCertification or Registration with CCMA, CMA, RMA, or NCMASuvida Healthcare provides equal employment opportunities to all Team Members and applicants for employment and prohibits discrimination and harassment of any type with regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation, and training.

Created: 2026-04-15