Population Health Coordinator - Prevention and Wellness Trust Fund (PWTF)


*This is a grant funded position*

The Prevention and Wellness (PWTF) Population Health Coordinator at the Lynn Community Health Center (LCHC) is part of an integrated and interdisciplinary primary care and behavioral health team working to improve processes and outcomes of care.  The PWTF Population Health Coordinator will support team providers, nurses and other staff in population management, including the ongoing  identification of patients that need follow-up for specific chronic conditions, and documentation of referrals to community agencies and/or specialty care.  The PWTF Population Health Coordinator on each team will collaborate with providers and other staff in meeting measureable outcomes in improving the management of chronic medical and behavioral health conditions including but not limited to pediatric asthma, Tobacco Use, Hypertension and Falls among the Elderly.

Additionally, the PWTF Population Health Coordinator participates in LCHC community outreach efforts, as appropriate and as assigned.  This may include participating in health screenings, health education programs or counseling at health fairs and other similar community events.


  • Respect and maintain patient confidentiality in all aspects of care including use of electronic information. 
  • Treat all patients in a welcoming and professional manner.
  • Demonstrate professionalism by appropriate attire, attendance, attitude, and behavior within work and community settings.
  • Contribute to the team effort by supporting all team members and maintaining an open and positive attitude.
  • Welcome new employees to the team by assisting with their orientation to the team and mentoring them, as requested.


  • Occasional evening and weekend hours may be required.


Under the direction of the PWTF Supervisor, team related responsibilities include:

  • Collaborate with other team staff in developing and implementing systems for managing and tracking patients with chronic conditions, facilitating the delivery of recommended care for patients  with specified chronic conditions.
  • Collaborate PWTF project team on QI efforts, specifically working with PWTF Care Management and Population Health Specialist to provide timely and useful information to the teams and providers.
  • Provide regular information to team providers, nurses and other staff on their panels of patients and assist in developing and implementing systems for assuring timely appointments and other follow-up communications with patients. 
  • Collaborate with community partners in documenting referrals electronically (e-referrals) to and from other agencies, i.e. School Department, Coalition for the Homeless, City of Lynn Health Department, Lynn Housing and Neighborhood Development, and Greater Lynn Senior Services.
  • Assist with preparing project reports
  • Participate in team meetings, and in establishing goals, objectives, protocols and procedures for population management
  • Participate in multi-disciplinary care coordination efforts
  • Maintain appropriate written and oral communication on a timely basis.
  • Establish and maintain an ongoing positive working relationship with all members of the health care team.
  • Document patient encounters and other communications, when appropriate, within established timeframes in the electronic health record.
  • Assure the prompt communication regarding changes and/or new problems to the PCP.
  • Support the overall team(s) and project(s) needs


  • Demonstrates an understanding of customer service principles by successfully completing on-line training.
  • Utilizes the principles of customer service when interacting with patients/clients, team members and staff from other departments.
  • Appropriately handles or seeks support when customer service breakdowns occur.


  • Demonstrates awareness of culture by successfully completing the on-line training on Cultural Competence.
  • Utilizes an appreciation of and respect for diversity when interacting with patients/clients, team members and staff from other departments.
  • Responds appropriately or seeks support when confronted with cultural biases or conflicts.


  • Is aware that in order to respond promptly and appropriately to emergencies, any staff member may be assigned duties, which differ from those in the job description or may be assigned temporarily to a different location.
  • Understands that all staff should have a Personal  Emergency Plan in place to best respond to his/her job responsibilities should health center emergency arise.


  • Participates in assessing and improving quality within the scope of responsibilities and throughout the organization as appropriate
  • Participates in health center-wide quality improvement activities as appropriate.
  • Advises appropriate personnel of quality issues and problems and makes recommendations for improvement.
  • Meets weekly with LCHC PWTF staff to assure coordination, maintenance of program goals and to identify any areas requiring changes.
  • Meetings as scheduled with collaborating partner agencies.


  • PWTF Supervisor/QI coach



  • Bachelor’s Degree required in applicable field.
  • Must be able to manage multiple programs/projects simultaneously with ease and efficiency, and  produce quality results in a fast paced environment
  • Ability to think and work independently and analytically on assigned projects to meet milestones and action items in a timely manner.
  • Effective time management, highly organized, and detail oriented
  • Superior communication, planning, and client service skills
  • Demonstrated integrity, dependability, sound judgment, teambuilding and resourcefulness to establish and maintain collaborative, positive, and effective working relationships with multiple and diverse multicultural environment of care and with community stakeholders
  • Ability to listen carefully to understand, respond, and problem-solve efficiently and effectively to address concerns and interests of LCHC
  • Strong computer skills, especially in MS Office suite products, e.g., Word, Excel, Access, and PowerPoint required.


  • 1-3 years of experience in a health care setting  and/or related experience in health/human services, social services or advocacy
  • Experience with data analysis and data presentation is preferred.


  • The essential duties of this position present risk of exposure to airborne infection, body fluids and blood borne pathogens.  Annual BBP Training is required.  Up to date immunization and annual TB testing is required.  Hepatitis B and annual flu immunization are strongly recommended.  All necessary vaccines are available at no charge at the health center.  A declination must be signed if the Hepatitis B or other recommended vaccines are declined.
  • Results of inquiry to Criminal Offender Record Investigation (CORI) must be acceptable under health center standards.

Lynn Community Health Center (LCHC) provides equal employment opportunities (EEO) to all employees and applicants for employment without regard to race, color, religion, sex, national origin, age, disability or genetics. In addition to federal law requirements, LCHC complies with applicable state and local laws governing nondiscrimination in employment in every location in which the company has facilities. This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, and transfer, leaves of absence, compensation and training. LCHC expressly prohibits any form of workplace harassment based on race, color, religion, gender, sexual orientation, gender identity or expression, national origin, age, genetic information, disability, or veteran status. Improper interference with the ability of LCHC’s employees to perform their job duties may result in discipline up to and including discharge. 

Job Posting ID # 17-111