As healthcare providers transition to outcome-based reimbursements, it is imperative that they make the transition to population health management to stay viable. Providers already have big data assets in the form of electronic health records and financial billing system. Integrating these disparate sources together in patient-centered datasets provides the foundation for probabilistic modeling of their patient populations. These models are the core technology to compute and track the health and financial risk status of the patient population being served. We show how the probabilistic formulation allows for straightforward, early identification of a change in health and risk status. Knowing when a patient is likely to shift to a less healthy, higher risk category allows the provider to intervene to avert or delay the shift. These automated, proactive alerts are critical in maintaining and improving the health of a population of patients. We discuss results of leveraging these models with an urban healthcare provider to track and monitor type 2 diabetes patients. When intervention outcome data are available, data mining and predictive modeling technology are primed to recommend the best type of intervention (prescriptions, physical therapy, discharge protocols, etc.) with the best likely outcome.