Director of Population Health

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Reports to: Chief Medical Officer; with a dotted line to EVP & COO

Manages: Population Health Program Manager, Specialists & Associates

Education/Training

• Nursing degree, Pharmacy degree or Master’s in Public Health or other related field.

Licenses/Certification:

• MSN, RN or PharmD required

• Board Certified Critical Care Pharmacist (BCCCP) preferred

• Board Certified pharmacotherapy specialist (BCPS) preferred

Required Qualifications and Skills:

• Minimum of 3-5 years of experience in healthcare leadership experience with significant experience in population health, care management, value-based care, or related areas.

• Must demonstrate integrity, sound judgment, demonstrated leadership skills, and strong interpersonal skills. 

• Experience working with quality metrics, healthcare analytics, utilization management and performance improvement.

• Understanding value-based reimbursement models and payer-provider relationships.

• Must be able to approach staff about quality issues with tact and diplomacy. Experience working with disadvantaged populations is helpful, and knowledge of health disparities is highly desired.

• Excellent oral and written communication skills needed; strong organizational ability required.

• Outstanding skills in data collection, analysis, and presentation. Experience in the use of spreadsheets.

Essential Job Functions:

• Practical knowledge of tools and techniques of continuous quality improvement, including analysis and interpretation of data using computer-based disease registries or similar data collection systems is essential.

• Assists in the development, monitoring, and presentation of internal quality measures and initiatives.

• Coordinating tracking and reporting of clinical outcomes, and follow-up of improvement action plans

• Responsible for developing methods for data collection and extracts data as required

• Assists with coordination of monthly meetings

• Prepares quality reports and statistics

• Participates in staff and management meetings as they relate to quality and population health activities

• Provides in-service training to non-provider staff in the area of quality improvement

• Reviews tools and surveys and provides technical assistance to staff

• Attends conferences and training sessions as requested

Quality/Value Based Care and Performance

• Support the design, implementation, and management of programs associated with Medicare Advantage, ACOs, Medicaid, commercial value-based contracts, and other alternative payment models

• Monitor quality, utilization, cost, and financial performance associated with value-based arrangements.

• Identify opportunities to improve performance on quality measures, shared savings, total cost of care, and other contractual metrics.

• Collaborate with finance, contracting, payer relations, and clinical leadership to translate contract requirements into operational strategies.

• Develop interventions to reduce avoidable emergency department visits, hospitalizations, readmissions, and other high-cost utilization.

• Deploy and monitor a MIPS strategy

Clinical Operations

• Direct the development and evaluation of population health programs addressing chronic conditions such as diabetes, cardiovascular disease, COPD, hypertension, and other priority conditions.

• Oversee initiatives related to preventive care, care gap closure, medication management, transitions of care, complex care management, and disease management.

• Partner with clinical leaders to integrate evidence-based population health interventions into routine workflows.

• Oversee maintenance and growth of ambulatory clinical pharmacy services

• Subcapitation clinical operations

• Social work & care coordination

• Operationalize and maintain remote patient monitoring (CGM), (CHF, HTN) to assist with meeting population health/value-based care goals.

• Clinical pathways for primary care (including pharmacy) and select specialty areas (cardiology, OR)

• Implementation of care teams and standard work associated to team based care

Population Health

• Develop and execute a system-wide population health strategy aligned with the organization's mission, strategic priorities, community health needs, and value-based care objectives.

• Lead population health initiatives across the system.

• Establish annual population health goals, priorities, performance targets, and implementation plans.

• Partner with executive and physician leadership to establish accountability for population health outcomes across the organization.

• Develop scalable models for managing high-risk, rising-risk, and complex patient populations.

• Promote an organizational culture focused on prevention, health equity, patient-centered care, and measurable outcomes.

Healthcare Equity

• Integrate health equity principles into population health strategy, program design, measurement, and resource allocation.

• Use demographic, geographic, clinical, and social data to identify disparities in outcomes and access.

• Develop interventions to address social drivers of health, including food insecurity, housing instability, transportation, economic insecurity, and access to behavioral health services.

• Partner with community-based organizations, public health agencies, schools, social service organizations, and other community stakeholders to improve health outcomes.

• Align population health activities with the organization's Community Health Needs Assessment and community benefit priorities.

Other duties:Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities and activities may change at any time with or without notice.

AGE AND DIVERSITY RELATED CRITERIA: Consistently treats patients, colleagues and visitors with dignity and respect, while being sensitive to the differing needs of all age groups, backgrounds, characteristics and cultures.

ABILITY TO FULFILL JOB EXPECTATIONS: Must have the ability to perform the essential functions of the position, including required work hours, locations and physical demands, without posing a direct threat to the health and safety of themselves or other individuals in the workplace, and with or without reasonable accommodation.

PHYSICAL DEMANDS:

• Frequently performs work in a professional office, clinical, and healthcare environment.

• Prolonged periods of sitting, standing, and walking throughout the workday.

• Frequent use of computers, keyboards, telephones, and other office equipment.

• Requires manual dexterity sufficient to operate standard office equipment and electronic systems.

• Frequent communication with physicians, leaders, staff, payers, community partners, and external stakeholders in person, by telephone, and through virtual meeting platforms.

• Ability to read, analyze, and interpret electronic and printed reports, spreadsheets, contracts, dashboards, financial data, and clinical performance metrics.

• Occasional bending, reaching, stooping, and lifting or carrying items such as files, reports, laptops, or presentation materials weighing up to 15 pounds.

• Ability to travel between organizational sites, physician practices, hospitals, and community locations as needed.

• Ability to attend meetings, presentations, conferences, and community events, which may require extended periods of sitting or standing.

• Requires the ability to concentrate, prioritize, analyze complex information, manage multiple priorities, and make decisions in a fast-paced environment.

• Must be able to respond to operational, quality, regulatory, and patient care issues as needed, which may require flexibility in work hours and schedule.

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Salary Range Details

The pay range displayed on each job posting reflects the anticipated range for new hires. A successful candidate’s actual compensation will be determined after taking factors into consideration such as the candidate’s work history, experience, skill set, and education. This is not inclusive of the value Sturdy Health’s benefits package (if applicable), which includes among other benefits, healthcare/dental/vision and retirement. For annual salaries this is based on full-time employment.

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Sturdy Memorial Hospital is an equal employment opportunity employer. There is no discrimination because of race, color, creed, age, gender, sexual orientation, national origin, veteran status or disability.