DIRECTOR OF POPULATION HEALTH

Position Purpose: The Director of Population Health will provide direction for value-based programs including Population Health, CARES, and Internal Credentialing through management of program applications. This will also include onboarding processes, care coordination services and ongoing development and deployment of performance maximization strategies. Additionally, the incumbent will be responsible for developing and maintaining meaningful payer and provider relationship with our managed care organizations and MSO's. This director will be responsible for oversight of population health cares and credentialing services with the assistance of the AVP of Population Health.

Provides ongoing VBS/HEDIS medical record collection and abstraction; and supports the abstraction of medical records related to VBS/HEDIS compliance initiatives. Provides accurate assessment of provider performance against VBS/HEDIS standards and procedures. Adheres to strict HIPAA confidentiality requirements for protected health information. Administrative oversight for all VBS and care management staff. Certify compliance with all ACOs and MSOs requirements and ensure all metrics are met.

Assist the AVP of Population Health in implementation of all aspects of the Care Management Program, including the identification of opportunities to improve patient care. Will be responsible for the planning, direction and coordination of care management operations, including quality, customer service, financial performance and regulatory compliance. Provide oversight to departmental staff.

Position Requirements / Qualifications:

Education/Experience:

Graduate from an accredited college or university with a minimum of an associate's degree in a health-related field preferred. Five (5) years' experience in a health care or related setting and a minimum of 2+ years in clinical care management. Experience working with culturally diverse clients. Knowledge regarding the Managed Care programs incentives and requirements to include but not limited to HEDIS, Pay for Performance, Medical Loss Ratio, and Utilization. EPIC Healthy Planet experience desired.

Licensure / Certification:

Maintain current CPR certification from the American Heart Association. Must have a valid Florida Driver's License.

Skills / Ability:

Excellent communication and interpersonal skills. Sensitivity in working with diverse cultural groups. Excellent interpersonal communication skills: Proven ability to solve problems and solution oriented. Ability to work independently and as a team member with fellow co-workers, directors, and other staff. Demonstrates flexibility in work schedule and job assignments. Strong computer skills required. Medical and Managed Care Terminology, Keyboard, Knowledge of Medicare, Medicaid and Managed Care coverage benefits/limitations, NCQA VBS/HEDIS requirements. Knowledge of ICD10 and CPT Coding. Basic computer knowledge is preferred

position:

POPULATION HEALTH DIRECTOR

POSITION RESPONSIBILITIES (non-EXEMPT POSITION)

• Provides visionary guidance on all of CHI's care coordination activities

• Serves as the primary point of contact for managed care organizations and MSOs on all value-based contracted business.

• Effectively communicates performance and participation expectations to population health staff, leadership, providers, and support staff.

• Remains versed on all Managed Care and ACO contractual agreements and ensures accountability towards provider reimbursement, incentives, and risk-bearing arrangements.

• Actively monitors and assesses contractual performance including financial and quality targets.

• Proactively spearheads collaborative efforts internally and externally focused on addressing gaps in performance,

• Facilitates appointments with health care providers including appointments to PCP for their health risk assessments, preventative visits, chronic care management, and Transition of Care.

• Ability to track, manage, document, identify, and report patient data. Ability to read and interpret medical documents.

• Facilitates the progress of various clinical and operational initiatives designed to improve quality, and reduce medically unnecessary, avoidable utilization of healthcare services, improve accuracy of coding and documentation, and manage program attribution in value-based programs.

• Monitors maintains subject matter expertise in the various forms of utilization of health services used by assigned populations.

• Effectively inspires department staff to excel.

• Works collaboratively with our CMO, Medical Directors and Director of Pharmacy to develop programs designed to influence the appropriate use of pharmaceuticals used by attributed members.

• Ability to interpret financial reports received from the MSO's and payer claims data to develop an action plan to mitigate financial loss.

• Works collaboratively with AVP Population Health, CMO, CFO, AVP PI and other leaders to develop the department.

• Prepares reports for PIC, Clinical Directors, Primary Care Committees as well as Joint Conference.

• Maintains knowledge of healthcare industry trends related to quality management, and linkage of compensation to performance.

• Ensures a fully integrated population health and care management program.

• Ensures department staff are held accountable for assigned metrics.

• Utilizes accountability tolls e.g., Microsoft Planner and Project to track action items.

• Maintain current licensure and/or certificates.

• Strong data entry skills; capable of using a computer efficiently and effectively.

• Develops workflows and department policies, procedures, and protocols.

• Ensures effective staff on-boarding and ongoing training.

• Attends scheduled in-services and trainings.

• Works to achieve patient outcome goals as established by the Health Plan.

• Promptly informs AVP of problems encountered.

• Follows CHI Policies and Procedures.

• Ability to prioritize, multi-task, and achieve goals on time; work independently and to self-motivate.

• Treat clients, team members and the public with courtesy, respect and present a positive public image. Treats patients with respect and dignity.

• Research medical history to determine most appropriate and likely source of necessary documentation.

• Ability to add the appropriate CPT Code to the tasks and notes.

• High production environment and, candidates must adhere to measured productivity requirements.

• Communicate effectively and expresses ideas clearly; actively listens and always follows appropriate channels of communication

• Participate in appropriate continuing education in service training.

• Reports to work on time and ready to work with minimal absenteeism.

• Adheres to Confidentiality Policies and Procedures / HIPAA Regulations.

• Well organized with the ability to maintain attention to detail.

• Performs other duties as assigned.

• Provides oversight for educational background, licenses, certifications, DEA, and work history for providers.

• Provides oversight for preparation, submitting, and tracking of initial and re-credentialing applications for health plans, hospitals, and government payers.

• Provides oversight of updates and maintains accuracy in credentialing systems, CAQH, PECOS, and NPPES).

• Provides oversight for compliance with accreditation standards (e.g., NCQA, Joint Commission), state regulations, and internal bylaws.

• Provides oversight for monitoring license and credential expiration dates, advising staff of necessary renewals.

• Interacts with providers, medical staff, insurance companies, and external organizations to resolve credentialing issues

• Provides oversight for accurate and timely credentialing processes for all initial applications and reappointments.

• Ensure credentialing documentation supports claims prevention and risk mitigation efforts.

• Collaborate with Risk Management to identify credentialing-related risk exposure, including licensure gaps, privilege discrepancies, or coverage issues and work to minimize risk.

• Support provider onboarding and offboarding to ensure accurate payer activation and termination.

• Assist RCM with resolving documentation discrepancies that impact enrollment timelines or billing.

• Work closely with the Payor Enrollment Department.

• Ensure alignment between credentialing completion and payer enrollment readiness.

• Communicate credentialing approvals, effective dates, and provider status changes.

• Conduct synchronization meetings with the outside credentialing software managers to review system updates, address challenges and barriers, and resolve credentialing workflow issues within the credential application software system.

• Serve as the primary liaison for HRSA and Joint Commission surveys, audits, and reviews related to credentialing and privileging, including preparation, documentation coordination, and surveyor response.

• Assist provider enrollment department with reconcile provider rosters across Credentialing, Payor Enrollment, Human Resources, Risk Management, and Revenue Cycle teams to ensure consistency and operational readiness.

• Ensure confidentiality, integrity, and secure handling of sensitive provider information in compliance with organizational policy, HIPAA, and regulatory standards

• Manage applications, reappointments, and privilege renewals for external facilities.

• Generate and distribute reports related to credentialing status, credential expirables, reappointment cycles, and provider readiness for clinical practice and billing.

• Support FTCA Deeming and Redeeming documentation and provider eligibility.

• Serve as a primary point of contact for credentialing-related inquiries from providers, leadership, and internal departments.

• Educate providers and internal stakeholders on credentialing timelines, documentation requirements, and dependencies.

• Meet with providers during the pre-employment process to review and obtain signatures on Medicaid consent and release forms and other managed care plan documents and respond to credentialing-related questions.

• Prepare and maintain complete credentialing and privileging files for review by: Credentialing Committee, Joint Commission, and the Governing Board.

• Assist with monitoring provider sanctions, exclusions, or reportable events in accordance with organizational policy.

• Coordinate and maintain provider credentialing and privileging with external hospitals, health systems, and partner facilities; while managing applications, reappointments, and privilege renewals for external facilities.

• Serve as liaison between the organization and external medical staff offices.

• Ensure alignment between internal credentialing status, scope of practice, and external hospital privileges.

• Supports credentialing committee meetings as needed.

• Audits health plan directories for current and accurate provider information.

• Ensures proper escalation of any issues impacting the completion of the application(s) or concerns brought forth by center/stakeholder.

• Completes accurate and timely data entry into the database to ensure consistency and integrity of the data.

• Tracks license and certification expirations for all providers to ensure timely renewals.

• Track appointment terms, recredentialing cycles, privileges, and credential expirables to ensure continuous compliance.

• Prepares files for presentation to leadership and the credentialing committee.

• Ensures timely and effective communication with centers and stakeholders on the progress of all applications and addresses any inquiries set forth.

• Provides monthly reports of credentialing and enrollment status to centers on the status of all assigned providers.

• Maintains current knowledge and ensures compliance with all accreditations, regulatory, health plan standards, and CMS.

• Identifies issues that require additional investigation and evaluation, confirms discrepancies and ensures proper follow up.

• Maintain accurate, complete, and current provider data within credentialing and privileging while performing analysis and appropriate follow-up of all applications.

• Oversees the collection, verification and securing of sensitive provider data through confidential sources and maintains a credentialing database.

• Oversees the processing of all appropriate queries for licensure, any appropriate regulatory credentialing requirements, and maintains documentation in the database.

• Proactively works with center designees to acquire necessary materials and information.

• Ensures all primary source verification is completed within the timeframe as allowed by regulatory and accreditation entities.

• Provides oversight for of document primary source verification (PSV) in accordance with organizational policies and regulatory standards.

• Oversees the development and implementati