Entity: Clinical Care Associates (CCA) - Penn Primary Care (PPC) and Penn Specialty Practices (PSP) of Penn Medicine Medical Group (PMMG)

Department: Regional Physician Admin

Location: 150 Monument Road

Hours: Per Departmental Needs

Summary:

Reporting to the COO, Population Health, the Director of Population Health Care Continuity is the leader accountable for designing, implementing, and leading an enterprise-wide post-acute management model that improves patient outcomes, reduces unnecessary utilization and readmissions, driving shared-savings performance in MSSP and other value-based arrangements. This leader will build and manage a preferred skilled nursing facility (SNF) network, oversee post-acute care transitions, optimize length of stay, and expand the use of home-based and self-care pathways as clinically appropriate.

The incumbent will lead shared clinical program development, including implementation of care initiatives, clinical pathways, and process improvement efforts across the primary care enterprise to deliver patient-centered care, coordination, and enhance patient experience outcomes. As an active participant in strategic planning for Population Health and Primary Care, the Director will work to strengthen integration between hospitals and primary care by improving access, reducing avoidable ED/inpatient utilization, and advancing patient satisfaction and quality performance.

Partners with physicians, care management, contracting, analytics teams, and post-acute providers to develop and optimize a high-value, patient-centered continuum of care supporting UPHS mission and performance goals.

Accountabilities:

Leadership, Operations and Clinical Quality Management
• Lead the development of new operational and clinical programs across PMMG with guidance from the COO by garnering support from key stakeholders, forming planning teams, developing financial projections and presenting plans various forums to gain approval.
• Design and oversee ambulatory nursing structure supporting Medicare Annual Wellness Visits, clinical phone triage and in-basket management.
• Administrative lead for the Penn Medicine and Tandigm ACOs directing practice engagement, patient experience, access, and change management.
• Serves as the principal interface for Penn Medicine Primary Care with all primary care practice sites and leads the engagement strategy. Responsibilities include: creating regular newsletters, updating the sharepoint site and coordinating biannual directors collaborative as well as monthly education activities.
• Regularly reviews staffing patterns of operational programs with Administrators to ensure appropriate assignments and staffing levels. Makes changes and/or recommendations to increase efficiency of clinic operations.
• Provides input for the development of primary care strategic plan and budget. Facilitates this process in partnership with primary care leadership and ensures that annual strategic goals are linked to entity and leadership's performance targets.
• Lead daily and weekly oversight of post-acute utilization, including SNF census, LO outliers, readmissions, and discharge planning.
• Develop workflows for real-time identification of high-risk discharges and proactive placement management.
• Collaborate with inpatient care management, hospitalists, and primary care to ensure smooth transitions and timely follow-up.
• Implement standardized clinical pathways for common post-acute conditions.
• Build and manage a team responsible for network performance, field operations, and SNF relationship management.
• Serves as point coordinator and leader for select PMMG functions as required or needed: Population Health Dashboards: Work with ambulatory operations group and PMMG practices in developing and standardizing ambulatory-specific outpatient dashboards, as well as practice specific metrics; facilitate communication and management by metric culture across ambulatory services.
• Effectively uses management and clinical information systems to monitor and improve work flow, revenue cycle performance, patient access and service performance.
• Addresses interdepartmental barriers to delivery of care including staffing, equipment and facilities. Ensures that care delivery in shared programs is consistent with policies and standards, federal and state laws and regulations, and accreditation requirements.
• Ensures coordination and preparation of timesheets for payroll, signs and monitors timecards in compliance with FLSA and approves leave time per departmental and Health Systems policies.

Program Development & Strategy Support
• Works with hospital and departmental leadership as requested in developing programs, services, and initiatives across the Health System that meet the needs of our primary care attributed patient population, anticipate future patient needs, build system loyalty, and generate profitable growth.
• Works in close collaboration with department/division/entity leadership to facilitate the development of clinical and research programs as they overlap in primary care clinical operational programs.
• Ensures selection and utilization of qualified, competent personnel. Uses appropriate efficiency information/data to determine staffing requirements. Provides opportunities for staff growth within area of specialty, which is reflected in professional/performance plans.
• Supporting initiatives for PMOD on-call services, templates standardization and optimization, clinical triage expansion, and patient experience monitoring.
• Design and operationalize a comprehensive post-acute care strategy aligned with MSSP, ACO, and population health goals.
• Build protocols that increase the use of home health, community-based supports, and self-care when clinically appropriate.
• Partner with contracting to structure performance-based agreements with SNFs and home-based care partners.

Performance Management & Analytics
• Create dashboards and reporting structures to monitor SNF quality, LOS, readmissions, functional outcomes, and cost performance.
• Use data to identify variation, drive accountability, and support continuous improvement.
• Partner with analytics to model shared-savings impact and forecast opportunities.
• Lead quarterly performance reviews with preferred SNF partners.

Relationship Management & Network Development
• Serve as the primary liaison to SNF leadership teams, home health agencies, and community-based organizations.
• Facilitate joint operating committees with preferred partners.
• Build strong relationships with inpatient and ambulatory clinical leaders.

Regulatory & Compliance
• Ensure workflows align with CMS requirements, MSSP rules, and internal compliance standards.
• Maintain awareness of evolving CMS programs and adjust strategy accordingly.

Communication
• Co-leads the Population Health Operations and Quality Committee, ensuring balanced attention in involving leadership of stakeholder departments, and providing periodic updates as needed regarding operational performance, including patient volumes/growth, staffing changes, patient satisfaction, process improvements, primary care program development, etc.
• Manages repository of valuable tools, guides and protocols, for learning, education, and practice accessible to all Primary Care clinicians, staff, and operational leaders through utilization of SharePoint, and newsletters.
• Communicates with the staff regarding primary care, specialty and Health System programs and initiatives through information sharing at meetings, grand rounds, and distribution of minutes as appropriate.
• Responds to and maintains utmost communication with COO's and Departmental leadership of key stakeholders: Clinical Care Associates/Penn Medicine Medical Group, Department of Family Medicine, Division of General Internal Medicine, Division of Geriatrics, Lancaster General Health Physicians, Princeton Health and others as required.

Education/Experience:

Required: Bachelor's Degree Business, Nursing, Health Care administration or related field And 10+ years Healthcare experience. Inclusive of 5+ years of prior management/leadership experience, preferably in a healthcare setting.

Preferred: Master's Degree MHA, MSN 6+ years' experience in post-acute care, care management, population health, or value-based care operations. Demonstrated success managing SNF networks or transitional care programs. Strong understanding of MSSP, ACO operations, and value-based payment models. Proven leadership and relationship building skills. Data-driven mindset with analytics experience.