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Description:

Holy Cross Physician Partners is looking for a motivated and engaged Population Health NurseClinical Managerto join their integrated health system! If you are a RN interested in improving access to and coordination of care for patients and providing high quality care to help improve patient outcomes, then our Population Health Nurse Clinical Managerrole might be for you. Come be a part of a team that is committed to safe transitions of care after discharge, getting the right patient at the right time to the right intervention, reducing unnecessary costs, promoting preventative wellness, managing chronic conditions, and educating and empowering patients to practice preventative medicine.

Better Care. Smarter Spending. Healthier People.

The Population HealthClinical Manageris a professional nurse Managerwho fulfils the responsibilities of a Population Health Nurse, provides supervision to the department's care management colleagues and acts under the direction of the Medical Director and Executive Director. Work includes, but is not limited to, oversight of day to day work flows, addressing staffing issues, developing work groups and collaborating with the Director on associate performance issues.

Direct Supervision of Population Health Nurse Staff

• Responsible for the daily operations of the assigned care management staff assuring that the staff is delivering the highest quality care management services to patients, families, physicians and other members of their team
• Available to front line staff, which may include travel to local ambulatory sites for problem solving within the areas of patient, family, insurance, resource, educational and or provider related issues
• Provides support to the care management staff on a daily basis which includes evaluation, development, mentoring, coaching, counseling and disciplinary actions
• Assists in recruitment, interviewing, and selection of personnel
• In collaboration with director and with input from stakeholders, prepares performance evaluations
• Provides on-going clinical supervision to the Population Health Nurses in both ambulatory and centralized settings and assists with the team's professional growth, development and on-going competence
• Works with colleagues in identification of quality issues and problem solving
• Organizes work groups that address on-going quality and process improvement initiatives
• Continually develops and implements service standards and clinical pathways, including quality auditing, training and development programs
• Actively promotes, participates and represents the department in various task forces, teams, and committees, as well as participates in various events representing the organization to the community
• Plans and runs monthly PHN meeting
• Assists in day to day role of a Population Health Nurse for a defined population as needed and as further specified below.

Collaboration between Population Health Nurses and Practice Transformation Specialists

• Leads engagement efforts for Physician partnerships between Population Health Nurses and Practice Transformation Specialists
• Tracks Key Performance Indicators (KPIs)
• Works with Analytics team and Director to prioritize workload based on strategy
• Plans and runs weekly PTS meeting

Direct Supervision of Clinical Integration Specialist (CIS) Staff

• Responsible for daily operation of Clinical Integration Specialist
• Ensures that this role supports Population Health Nurse team to improve quality and lower cost

Care Transition Coaching and Coordination

• Ensures that care for high-risk patients is provided across the continuum of the health care experience, which includes care transitions, coordination of community and social services and other health care providers as needed
• Facilitates information flow between hospital, long-term care, specialists, home health representatives, health plan and all others on the care team
• Provides and facilitates open communication with physicians, office staff and health plans as appropriate
• Consults with all health plans on specific issues related to evidence-based guidelines, gaps in care, and overall care plans, and coordination of patient care and communication.

Population Management

• Works collaboratively with physicians and the care team to ensure patient adherence to the medical plan of care and/or evidence-based medicine guidelines, including all appropriate preventive and disease-specific screenings, interventions, and treatment goals; including self-management goals, and contact schedules
• Track performance of clinical outcomes for population; document as necessary.

Targeted Reviews of Medical Documentation

• Utilizes provided guidelines to determine if guideline criteria have/have not been met relative to HEDIS, HCPP, PQRS and/or other quality of care standards as well as administrative or efficiency measures.
• Communicates findings with providers and other stakeholders
• Assists in the education of providers and staff on proper documentation and coding
• Assists in the education of providers and staff on the use of clinical reporting tools.

Work Flow Process Facilitation

• Provides instruction and coaching to practice office staff on motivational interviewing/coaching
• Assists practice with work flow improvement processes to support improved office efficiency and patient-centered management.
• Participates in the development, implementation, and outcomes assessments of quality improvement projects.

Health Plan Clinical Liaison; Utilize Health Plan Data and Portals

• Acts as clinical point of contact for health plan’s clinical and administrative teams
• Participates and/or leads health plan meetings.
• Become proficient in the access of various health plan applications for the purposes of viewing, modifying, editing, extracting and/or saving clinical and administrative data pursuant to departmental goals.
• Utilizes HCPP, HCH, HCMG or other applications to validate or compare health plan data.
• Updates or modify health plan data pursuant to medical record review upon direction of management.
• Meets with health plan representatives to further mutual clinical and administrative goals

Demonstrate reliability in accepting and fulfilling various roles. Perform other job related duties within job scope as requested

• Must complete a minimum of one (1) A3 Process Improvement Project per year. Project aims for Better Care, Smarter Spending and/or Healthier People as the Accountable Care Organization (ACO) Mission
• Adapts to change or usual circumstances in a way that promotes cooperation and minimal disruption to work environment.
• Understands and self-manages to support HCPP-level success goals, including improvements in quality, cost of care and patient experience for the CIN’s population.
• Identifies opportunities for improvement (at individual, clinic and CIN levels) and actively works with healthcare and HCPP team to correct or improve results.
• Presents a positive and professional appearance; convey a professional demeanor

MINIMUM KNOWLEDGE, SKILLS AND ABILITIES REQUIRED:

• Current unrestricted license by the State of Florida as a registered nurse
• Bachelor's degree required
• Must lead by example and possess superior customer service skills and professionalism
• Must exhibit flexibility to adapt to ongoing changes and work in a fast-paced, customer driven environment
• Must have interpersonal skills to drive collaboration, commitment, and productivity when working with cross-functional teams, customers, and end users
• Must possess leadership qualities including time management, verbal and written communication skills, listening skills, problem solving, decision-making, diplomacy, priority setting, work delegation and work organization
• Experience in patient education is required
• Strong ability to communicate effectively using written and verbal skills
• Proficient in email communications and internet usage along with basic use of Microsoft Excel and Word
• Knowledge of information technology to evaluate care effectiveness (care process, outcomes and cost) for individual users of health care and patient populations
• Certification as needed or available for Health Coaching or Population Health Management
• Basic Life Support (BLS) for the Healthcare Provider certified or obtained by the end of the orientation period
• Ability to work autonomously within matrix environment without direct supervision or support
• Demonstrates a wide theory base and sound clinical skills to function as a nurse generalist

PREFERRED KNOWLEDGE, SKILLS AND ABILITIES:

• Master's degree preferred
• Previous management experience preferred
• Performance Improvement / Enterprise Performance Excellence experience preferred
• Five years of clinical and case management/health coach experience is preferred
• Certification in case management (CCM), public health and/or community health preferred

Our Commitment to Diversity and Inclusion

Trinity Health is a family of 115,000 colleagues and nearly 26,000 physicians and clinicians across 25 states. Because we serve diverse populations, our colleagues are trained to recognize the cultural beliefs, values, traditions, language preferences, and health practices of the communities that we serve and to apply that knowledge to produce positive health outcomes. We also recognize that each of us has a different way of thinking and perceiving our world and that these differences often lead to innovative solutions.

Our dedication to diversity includes a unified workforce (through training and education, recruitment, retention, and development), commitment and accountability, communication, community partnerships, and supplier diversity.