Manager, Population Health

At North Bay Health, the Manager, Population Health oversees a staff that includes Population Health RN Case Managers, Social Workers, Resource Specialists, Diabetic Educators, Licensed Vocational Nurses and other staff who are responsible for patient care coordination with the goal of reducing readmissions and frequent ED visits. In collaboration with the Care Management Director, the Population Health Manager will ensure that comprehensive care coordination efforts will be made on behalf of high utilizer and frequently readmitting patients to significantly reduce unnecessary hospital readmissions and unnecessary ED utilization.

The Manager, in coordination with the Director, ensures optimal team performance and accountability for ensuring implementation of robust social work and care management interventions that ensure reductions in preventable ED visits and hospital readmissions. The population health manager ensures that program objectives, design and operations are closely aligned with organizational strategic objectives and performance metrics including but not limited to Vizient readmission reduction targets, reduced total hospital admission targets for capitated populations as well as readmission targets for population health performance incentive programs.

The population health manager will identify key measures of success (e.g. readmissions, ED utilization and overall hospital admission rates), and implements key processes to maximize efficient resource utilization. They will assume overall responsibility for coordinating/managing patient centered care activities, and ensures cost effective, quality patient outcomes through the supervision of clinical/professional staff, and collaboration with medical staff, nursing, and support staff.

Ensures compliance with state/federal and other regulatory and accreditation body requirements.

Provides leadership and guidance while creating and sustaining an innovative environment that supports excellence in care management. This includes informed program development through the continuous assessment, planning, implementation and evaluation of programs and standards that support positive patient care outcomes.

Responsibilities include:

• Implements effective team oversight to ensure continual robust care management and social work interventions to reduce unnecessary acute utilization in patient populations.
• Ensures team accountability and performance to meet key organizational strategic objects including reduced readmission rates and reductions in overall hospital utilization.
• Consistently tracks team productivity and team performance data to ensure key program objectives are being met.
• Effectively makes adjustments in program workflows and program interventions as needed to ensure optimal program performance in meeting system strategic objectives.
• Ensures that all team members are routinely visiting patients face-to-face both in the hospital and in the community (homeless shelters, SNFs, etc.) to ensure maximum patient engagement and effective care management program interventions.
• Ensures effective implementation of the Enhanced Care Management program (EMC) and other community partnership initiatives.
• Assures Care Management interventions are documented with the patient, family or other identified support, and members of the entire care team to meet patients’ needs.
• Acts as liaison to post-hospital care providers, health plans and community partners.
• Ensures that patients that are high risk for psychosocial/environmental negative impacts, receive timely, coordinated social services interventions.
• Is flexible as a leader meeting organizational strategic objectives when priorities change.
• Performs duties as assigned.