Population Health Manager

Responsibilities

• Collaborates with CentraState’s physicians, health coaches and department leaders to meet clinical, operational, and business objectives to improve the health of target populations.
• Develops and maintains reporting, quantitative analysis, decision support and evaluation of the impact of interventions.
• Defines and creates the technical processes to convert, map and extract data from disparate sources, over interfaces and into the target reporting framework while validating data quality, continuity and conforming to HIPAA regulations and ensuring compliance with organizational data security and privacy requirements.
• Demonstrates a strong understanding of the technologies used, industry-specific issues, regulatory requirements, and current healthcare reform regulations.
• Ensures that the data is understood by users.
• Incorporates government and commercial payer claims data, health risk assessments and electronic health record (EHR) data to discover gaps in care and stratify risks of target populations. Identifies opportunities for intervention.
• Researches and applies knowledge regarding health policy and reimbursement requirements.
• Submits reports to government agencies as required.
• Thinks critically to identify trends, draw conclusions and create dashboard reports for key stakeholders.
• Works with business, technical, and clinical colleagues to improve patient outcomes and reduce costs for CentraState’s managed population.
• Assists AVP with all aspects of grant funded programs, including budgets, grant narratives, research and quarterly data submissions.
• Develops data tools to track patient outcomes for grant funded programs and internal programs as well.
• Manages and/or generates ad-hoc reports, validates data, develops and monitors ongoing performance metrics.
• Manages Diabetes Prevention Program digital platform data integrity and appropriate utilization by instructor. Tracks participant engagement. Troubleshoots user/admin errors as needed.
• Generates required Diabetes Prevention Program and Hypertension Management Program reports to the CDC to attain and sustain full recognition status. Assures data integrity.
• Liaisons with AHS partners to align and apply consistent standards regarding CentraState’s approach to population health/integrated care management and reporting.
• Guides and maintains RN Health Coach and Health Equity Coordinators care coordination referral documentation and follow up.
• Collaborates with Quality data team and inpatient clinical teams to achieve standards set forth by QIP-NJ program. Responsibilities include dissemination of data to appropriate parties, manual chart abstractions, data entry and data submission.
• Creates and maintains detailed guides for EPIC documentation process for Community Health Workers, LSW, and RN Health Coaches. Troubleshoots and gives ad hoc support to across departments for IT related issues, EPIC related issues, workflow issues, and other relevant concerns.
• Manages data entry and data reporting for all off-site vaccination events. Ensures that vaccinations are documented in a timely and accurate manner in NJIIS as needed, and that all vaccinations are reported accurately to the DOH for vaccination grant.
• Represent CentraState at the Population Health Committee Meetings of Healthcare Transformation Consortium. Assist Regional Medical Director of AMG Family Medicine and AHS Medical Director of Integrated Care with development of a post-acute scorecards and other objective quality improvement solutions.
• Identifies trends and develops solutions or programs in three areas of focus – Health Equity, Transitions of Care and Social Determinants of Health. Serves as a subject matter expert for internal and external audits, and surveys. Presents information on hospital initiatives to Board of Trustees, hospital committees, and external agencies as requested.\
• Health Disparities/Equity
  • Develops diagnosis-specific disparity reports using System tools to satisfy Joint Commission and CMS Health Equity mandates and/or program accreditations. Collaborate with AHS Director of Planning and System Development on Disparity Reports and Community Health Needs Assessments. Analyzes reports and assists in the development of the organization’s disease-specific action plana.
  • Creates and Manages services offered to vulnerable populations to address health disparities and inequities among hospital patients and within the community (e.g., health screenings, vaccinations, and referral programs to medical homes, TOC, and insurance programs).

• Leads CentraState’s participation with the QIP-NJ Program. Understands complex requirements for data abstraction and agency submission, problem solving with the Quality Team, disseminating information across departments and with AHS corporate leaders.
• Transitions of Care – Chronic Disease
  • Collaborate with AVP, Pop Health Director, RN Health Coaches and AHS Integrated Care Team to develop transitions of care programs for patients with chronic conditions, including but not limited to Heart Failure, Pre-eclampsia, Hypertension, and other TOC programs for chronic conditions.
  • Leads projects with AHS partners to build workflows, smart forms, and other data collection tools in the EMR. Works with AHS partners to build reports specific to chronic disease management programs.

• SDOH
  • Develops and maintains SDOH screening program. Oversees workflows, guidance documents, smart notes, and a referral mechanism to refer patients to inpatient social work for appropriate care before discharge. Analyzes organization screening performance and patient social care needs.
  • Manages and grows a preferred referral network for SDOH related needs.

• Leads CentraState team and liaisons with AHS team to create a cohesive front for reporting and implementing new processes at CentraState and across the health system. Project lead for QIP-NJ Learning Collaboratives on SDoH.

• Directs house-wide workflows of SDoH screenings and follow up referrals to CBOs and FBOs. Expands the program to additional units/departments as needed. Assures that documentation in the EMR is appropriate. Manages compliance for screenings. Provides education and retraining as required. Holds staff accountable for performance metrics.
• Manages LSW and health equity coordinator roles (or similar workers) to assist with and close referrals for patients with complex social need referrals to community-based organizations. Collaborates closely with the Director of Patient Access & Care Management to assure effective handoffs.
• Manages the relationship with social care referral platform service provider to assure community-based organizations and community partners are onboarded to the platform and up to date. Reports any non-responsive community partner to the platform service provider as needed.

Qualifications

• Bachelor’s Degree in Public Health, Healthcare Administration, Community Health or related field required
• Master’s degree in Business Administration, Health Care Administration or equivalent preferred
• Five years’ management experience in the health and wellness field required with broad understanding of the evolution of healthcare reimbursement and the impact on patients, payors and providers
• Skills in leadership, problem solving, project management, performance improvement and goal setting required
• Experience working within a complex multi-site or integrated system preferred
• Strong interpersonal and written and verbal communication skills required
• Clinical background or experience in designing clinical programs
• Demonstrated understanding of health risk management
• Data comprehension and analysis skills
• Prior product development experience with health promotion/behavior modification programs
• Ability to conceive of new ideas and execute plans to completion
• Understanding of evolving reimbursement structures
• Grasp of issues surrounding Pay for Performance, Hospital Readmision and HEDIS a bonus

About Us

Sitting; typing; standing; walking.

Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.