About FCHC:
Since 1976, Florida Community Health Centers, Inc. (FCHC) has been a health care leader in Florida. We provide comprehensive primary and specialty health care and patient support services through a network of Centers surrounding Lake Okeechobee and across Florida’s Treasure Coast. Our mission is to ensure that everyone in our communities has access to culturally competent, high-quality health care that they can afford. FCHC has locations in Clewiston, Moore Haven, Okeechobee, Fort Pierce, Port St. Lucie, Stuart, Indiantown, Pahokee and West Palm Beach. FCHC’s Corporate Office is centrally located in West Palm Beach, Florida. FCHC has multiple staff members who speak Spanish and Creole, and translation is available for other languages as needed. FCHC has created a “one-stop shop” for patients–providing Pediatric and Adult Primary Care, Dental, OB/GYN and Women’s Health, Infectious Disease, Behavioral Health, Pharmacy, chronic disease education and care management, referral assistance, benefit enrollment assistance and coordination, and telehealth services. Our patients benefit from a “medical home” model, where they may access our extensive array of health care clinicians and services in an atmosphere where they are treated with respect, care, and concern.
Mission
The Mission of Florida Community Health Centers, Inc. (FCHC) is to provide accessible, cost-effective, high-quality, comprehensive health care to all persons in our communities.
Vision
Florida Community Health Centers, Inc. (FCHC) will maintain strong leadership in, and advocate for, the provision of health care services.
FCHC will foster and promote collaborative relationships and will develop partnerships with local, state, and federal public health service agencies and the community in general, to enhance the quality of delivery systems for comprehensive health care. FCHC will be an employer of choice and will demonstrate excellence with a highly trained staff and governing board.
Values
FCHC values Integrity, Compassion, Commitment to serving others (external and internal to the organization), Innovation, Effectiveness (cost and outcome), Efficiency, being Mission-driven, Commitment to serving others internal to organization and Commitment to Excellence.
Position Summary: The Population Health Outreach Associate supports Florida Community Health Centers’ value-based care efforts by conducting proactive patient outreach, scheduling, and follow-up for Sunshine Medicaid, ACO, and Medicare patients. This role focuses on bringing patients into care, coordinating timely post-discharge follow-up (ED, inpatient, behavioral health), and helping close care gaps by ensuring patients complete ordered labs, screenings, and follow-up appointments. The Outreach Associate works closely with the population health clinician and other clinician teams to support a consistent, high-quality patient experience, improve continuity of care, and strengthen performance on key quality measures.
Roles and Responsiblities:
- Conduct proactive outreach to Sunshine Medicaid, ACO, and Medicare patients to drive visit completion and care gap closure.
- Schedule appointments within EHR (Epic) with a target appointments per week, prioritizing patients with open care gaps, overdue visits, or recent external care utilization.
- Perform daily outreach to patients discharged from ED, inpatient, and behavioral health settings; facilitate follow-up scheduling within established timelines (24-48hr outreach and 7 day follow up)
- Coordinate scheduling with the appropriate provider, including the designated population health clinician, based on urgency and complexity.
- Track care gaps (e.g., A1C/diabetes follow-up, BP follow-up, CRC screening, mammograms, preventive visits, medication adherence) and document progress in the EHR and/or tracking tools.
- Follow up with patients and clinician to ensure completion of ordered labs, imaging, and screenings; provide clear instructions and remove barriers when possible.
- Close the loop after visits by confirming care gaps were addressed; communicate with clinical teams when gaps remain open and support resolution (e.g., missing orders, incomplete follow-through).
- Use payer and quality tools (e.g., Availity and plan portals as applicable) to identify gaps, confirm eligibility, and support outreach lists.
- Maintain accurate documentation of outreach attempts, outcomes, scheduling actions, and barriers to care.
- Provide routine performance updates to the supervising leader and participate in huddles/meetings to prioritize work and review progress.
- Maintain HIPAA compliance and handle sensitive patient information appropriately at all times.
- Monthly roster reconciliation for our value based contracts
- “New to you” outreach to bring assigned members in
- Ensure correct PCP attribution and panel assignment in your HER
- Provide monthly provider roster report
- Support in other value based care activities, including but not limited to meetings and communication with payor teams. Developing relationship with payor teams to improve support in patient quality of care.
- Develop reports and create powerpoint slides to share work in progress and successes
- Support in analyzing reports and elucidating insights from data
- Work adjacent scheduling lists to ensure all patients have access to care
- Participate in regular clinic visits and patient outreach events in coordination with outreach team
Qualifications and Education Requirements:
Minimum Requirements (experience, training, and education): To effectively fulfill this position, candidate must meet the following requirements:
- High school diploma or equivalent required (associate/bachelor degree preferred).
- 1–3 years of experience in a medical office, scheduling, outreach, referrals, care coordination, call center, or similar patient-facing role. Sales experience also acceptable.
- Strong phone-based communication skills; able to conduct high-volume outreach and scheduling professionally and efficiently. High energy preferred.
- Proficiency with EHR systems (Epic preferred) and computer skills (email, spreadsheets, documentation).
- Highly organized with strong follow-through; able to manage multiple priorities, patient lists, and deadlines.
- Works to achieve clear performance metrics and mission oriented to serve underserved populations.
- Ability to work effectively with clinicians, nurses, MAs, front desk teams, and quality staff.
- Highly motivated and flexible to adjust responsibilities to meet needs of patients and organizations
- Demonstrated professionalism, discretion, and reliability.
Benefits:
- 401(k) matching
- Dental insurance
- Employee assistance program
- Employee discount
- Health insurance
- Life insurance
- Loan forgiveness
- Paid jury duty
- Paid time off
- Professional development assistance
- Retirement plan
- Tuition reimbursement
- Vision insurance
Work Location: In person
