Description

PRINCIPAL DUTIES AND RESPONSIBILITIES:

• Develop strategies to achieve the quadruple aim; supervision of all personnel pertaining to population health management (PHM) and clinical quality improvement (CQI) programs; and overseeing the administration of care coordination programs, training and care management staff to include:
  1. Develop workflows and protocols designed to guide the team activities; ensuring that these areas operate and support the tenets of PCMH
  2. Directs the design for implementation and evaluation for standardized electronic systems and resources for care coordination
  3. Provides on-going training to staff on evidenced based intervention strategies, care planning and related care management delivery methodologies.
• Responsible to measure clinical care outcomes through the compilation and analysis of data and communication of results.
• Maintain population health programs including the Patient Centered Medical Home (PCMH) model of care, chronic disease programs e.g., diabetes, obesity, hypertension, and work to support provider relationships and improve internal communication related to system initiatives.
• Provide analytical support to senior leadership related to the identification of new opportunities that would positively impact quality performance and reduction of inappropriate utilization/medical spending.
• Sustain and expand PHM programs, including but not limited to PCMH and chronic disease programs, including those focused on diabetes, obesity, hypertension, etc.
• Serve as the point of contact for all value-based programs including: Patient Centered Medical Home (PCMH) and Advance Primary Care (APC), DSRIP, MU, and Merit Based Incentive Payment Systems (MIPS)
• Supervise all programs and personnel pertaining to PHM, Care Coordination and CQI: Case managers and care coordinators, Clinical Quality Coordinator, and Patient Navigator(s)
• Supervise clinical initiatives including grant-funded programs - AIMS, SUD-MH, Case Management for population health/SBIRT/CCM
• Responsible for ongoing PCMH reports and maintaining PCMH standards of care
• Generate, review and monitor all reports pertaining to PCMH, APC, VBP programs to guide team activities and ensure program goals are being met including UDS, CQI (including taking minutes)
• Conduct data analysis to identify trends and patterns related to care outcomes
• Develop action plans to address negative findings; support necessary workflow redesign to meet state and federal benchmarks
• Work with clinical staff to implement streamlined and efficient workflow changes
• Support practices' utilization of available Care Management programs
• Aggregate and interpret operational and utilization data in order to identify populations that would benefit from new programs or interventions, as well as evaluate the effectiveness of clinical programs and/or specific interventions
• Leads projects which may involve elements of data analysis and performance improvement to implement system changes
• Identify trends in data, including those that were not necessarily being activity monitored, which may have an impact on departmental performance and/or member outcomes Communicate actionable findings and provide recommendations as appropriate to management
• Develops policies, procedures, workflows and protocols designed to guide the team activities; ensuring that these areas operate and support the tenets of a value-based programs
• Provides on-going training to staff on evidenced based intervention strategies, care planning, and related care management delivery methodologies
• Provides administrative support for all CQI activities: track/monitor/review reports due, enter results into dashboard including dates reported, prepare CQI minutes and carry over old business into next month's agenda, prepare agenda's, follow up with responsible parties on submission of reports; assist with PDSA cycles; assists department heads in the development of QA/QI measures and annual targets
• Quarterly review of all measures for UDS (UDS reports generated by the Clinical Quality Coordinator); oversee HRSA-UDS reporting requirements and ensure timely submission of all UDS reports

Requirements

Required Knowledge, Education, Skills, and Abilities:
• Bachelor's degree required; Master's degree (MS, MPH, MBA) or other licensed clinical degree (LPN, RN, NP, MD) preferred
• 5-7 years ambulatory care experience preferably in a large medial group, or healthcare system required - preferably primary care
• Experience managing projects in health care quality improvement and management, performance improvement, and/or practice transformation.
• Experience with programs and care models for high-risk individuals as well as Medicaid/Medicare and uninsured populations.
• Evidence of essential leadership, communication, education, and counseling skills
• Well-versed in social determinants of health
• Working effectively both as a team member and on individual efforts and timelines.
• Ability to manage a business unit/multiple lines of business, while also leading and working on one or more projects
• Leading project teams through highly intensive, long-term, large-scale project work
• Advanced proficiency in Microsoft Access and Excel required
• Well-versed in E.H.R and reporting; eClinicalWorks (eCW) experience desirable
• Excellent interpersonal, oral and written communication skills
• Strong organizational and project management skills
• Excellent judgment and creative problem solving skills
• Proven track record of accountability and results