The Director of Population Health Care Management for Eastside Health Network provides clinical leadership and strategic direction in the design, development, implementation and operations of innovative approaches to ambulatory clinical management with a focus on current and future accountable payer models to include, incentive-based, shared and risk based, including full risk within the Eastside Health Network. This position will be responsible for the development and oversight of the population-based care management and utilization program for Eastside Health Network contracts, assuring appropriate levels of staffing, effective and efficient teams, a sound infrastructure and appropriate policies to produce excellent outcomes. The Director will engage and collaborate with internal and external stakeholders, to include network and hospital leadership, Eastside Health Network committees, hospital care management teams, physicians, payers, local and national organizations on methods and best practices of identifying and improving patient health outcomes, patient satisfaction and efficiencies. The Director is accountable for achieving established performance targets, goals, standard work, protocols, documentation standards and outcome reporting for all programs. The Director will ensure that the department is in compliance with all applicable payer standards and contracted requirements, ensuring all work is meeting short term and long-term goals that will be achieved in a manner that is consistent with the mission, values and strategic goals of the network and health system. The Director reports directly to the Eastside Health Network Executive Director with a matrix reporting structure to the local Hospitals and Medical Directors.
Essential Job Functions:
License, Certification, Education or Experience:REQUIRED for the position:
- Provides day to day direction to the Care Management and Utilization Management teams (Care Managers, coordinators and Population Health Analysts) to meet network targets, goals and objectives. Identifies opportunities for process improvement. Integrates, coordinates and collaborates with all disciplines along the continuum of care, including clinics, owner and independent providers, hospital departments, EHN committees, and payer partners to develop work flows, reporting mechanisms, and communication pathways to improve patient and network outcomes. Develops and updates policies and procedures. Acts as a role model to implement necessary change.
- Ensures that members are identified through risk stratification, utilization, referral or identified by payers for care management/disease management and have a comprehensive care management plan, utilizing the case management process (Assessment, plan, implementation, monitoring and evaluation). Utilizes clinical standards for closing care gaps, performing episodic care management, transitions of care and chronic disease management. Involves patients, families, physicians, healthcare team members and payer representatives as appropriate.
- Establishes and maintains documentation standards that optimally provide for effective and efficient delivery of patient care. Ensures that interventions, visits, and referrals are documented in the appropriate information systems.
- Develops and manages operational and capital budgets, establishing appropriate staffing levels consistent with targeted productivity. Reviews caseloads and adjusts as appropriate for efficient, effective services utilizing regulatory standards, and maintaining budget allocations.
- Recruits and selects new staff. Provides and holds staff accountable to orientation, education, mentoring and training, both verbally and in writing, to include health plan contract and operations information, along with specific competencies of job functions. Provides performance reviews and performance improvement activities in a timely manner, to include discipline, corrective action plans up to and including discharge. Creates a collaborative team working with all disciplines along the continuum of care which impact care management and utilization management outcomes.
- Directs the processes necessary for data collection, data review, analysis, decision-making, report maintenance and reporting of pertinent integrated information, reports and dashboards. Monitors and tracks utilization trends and variances. Implements process improvement strategies and corrective action plans as appropriate to improve health outcomes, decrease of cost of care and improved efficiencies.
- Maintains comprehensive working knowledge of payers, including incentive and risk-based contracts and regulatory requirements assuring that all care management and utilization management functions and strategies meet Health Plan and Regulatory requirements. Maintains knowledge of Local and National best practices for care coordination/navigation, case management, utilization management, and disease management, to support effective population health strategies and tactics.
- Maintains thorough working knowledge of provider performance, reporting, registry tools, and databases to support performance. Monitors, interprets, and reports on changes in performance, patient trends, provider actions, and payer reports that may impact network goals and outcomes.
- Provides support and/or leadership for key network meetings which could include Board, Network Provider, Utilization, and Payer meetings.
- Leads, assigns, and/or participates in special projects and assignments as required.
DESIRED for the position:
- BSN in Nursing, Master's degree preferred in Business, Nursing, or Healthcare Administration.
- Current licensure as an RN with the Washington State Department of Health
- 5 years of clinical experience
- 3 years in case management and utilization management experience
- 2 years Management or leadership experience, formal or informal
- Knowledge of computer systems (spreadsheets, databases) and ability to train others.
- Knowledge and ability to apply the principles of Performance Improvement.
- Understanding of current healthcare financial issues and delivery of care across the continuum
- Possess leadership process knowledge and skills.
- Current knowledge of all government and payer regulatory requirements
- Current knowledge and experience of utilization management using nationally accepted guidelines and decision support criteria
- Demonstrated oral and written communication skills, visual and aural skills in order to communicate, ensure, and deliver safe care to patients and to provide a legal record of care.
- Performs work within strict quality, budget, and timing guidelines, striving for efficiency and efficacy, and identifies opportunities for process improvement.
- Certification in Case Management (CCM, ACM, etc.)
- Case Management management/leadership experience preferred