Under the direction of the SVP Population Health and CHRISTUS Health Plan, the Director of Medical Management and Population Health Management will provide expertise in Care Management and Population Health Management. This includes proactive application of strategies and interventions to defined cohorts of individuals across the continuum of healthcare delivery in an effort to maintain and/or improve the health of the individuals within the cohort at the lowest necessary cost. The Director of Medical Management and Population Health Management will assist with and oversee the development and implementation of a proactive, patient-centric approach to health and healthcare that engages patients and physicians in prevention, wellness, care coordination and care management with the goals of improving outcomes and reducing costs. These initiatives should be coordinated with, and supportive of, existing managed care contracts (CHRISTUS Health Plan, Medicare, Medicare Advantage, and Commercial agreements) that the organization has in place or is currently seeking to secure. The Director of Medical Management and Population Health Management will provide support and leadership in areas of successful value based contract execution, clinical performance, process improvement, data collection, data interpretation, etc. for the organization, working closely with the Executive Leadership and Clinic Operations
Responsible for developing Medical Management and Population Health Management programs that apply the CHRISTUS Health Plan mission, vision and values, healthcare science, incentives, and information to improve Care Management and assist consumers and their support system to become engaged in a collaborative process designed to manage medical/social/mental health conditions more effectively.
Works collaboratively with the Executive Team and physicians to provide strategic planning and implementation support for transition to Population Health Management.
Uses the Population Health Steering Committee's recommendations and timelines as guidance to implement the transition to Population Health Management.
Performs a key role in the development, implementation, coordination, and monitoring of clinical programs (e.g. Chronic Care Management, High risk patient care management, care coordination, transition of care, etc.) to support successful participation in Medicare Shared Saving Program, Medicare Advantage, MIPS, MACRA, APMs and commercial Value-Based care arrangements.
Supervises, directs, and manages the Population Health Management care staff (e.g. health coaches, analysts, etc.) that are responsible for the smooth deployment and standard operation of clinical programs and services which benefit the patient population.
Analyzes and uses relevant information and data to guide the development and implementation of transitional care and care management interventions that improve value to the patient and payers. In addition, presents information and data that describe the progress of PMH program to Executive Team, Finance committee and Population Health Steering committee.
Shares data with the appropriate stakeholders and works with Marketing and external vendors, when applicable, to communicate accomplishments to the public.
Works closely with Information Management and Information Technology departments along with input from Operations, to design, improve and implement solutions for using technology to support population health management processes, access to care, patient engagement, and efficient care management workflow across the organization (e.g. EMR workflow and template changes, etc.)
Works with the contracting and legal counsel to support the negotiation and monitoring of performance and/or risk based contracts with payers, and serves as liaison to the carrier's representatives.
In this dual role, the Director of Medical Management and Population Health Management is accountable to the Executive Director of the Health Plan and works with the executive leadership, regional chairs and system directors to assist with promoting the advancement of primary care and interdisciplinary/specialty collaborative care teams both internally, as well as across external network of providers and/or other community care partners.
Works with the executive leadership and the Population Health Steering Committee to assist in the development of strategies to engage physicians and staff in population health management.
Responsible for health plan and regional standardization of nursing practice, clinical documentation and medically related use of evidenced based care guidelines that aide in improved patient outcomes and ACO reporting.
Serves a vital connection between Medical Management and Population Health for the coordination of Care Management services and Population Health outcomes for all lines of business, indigent populations and DSRIP programs.
Responsible for chairing and coordinating the Best Practices and oversight functions of the Medical Management Committee, Physician Advisory Committee and Medical Operations Committee.
Works with the Chief Financial Officer to develop and manage the budget for Medical Management department.
Adheres to and supports all Clinic-wide, as well as departmental, policies and procedures, continuous quality improvement objectives and safety standards.
Develops the CHRISTUS Health Plan Care Management and Utilization Management Framework that is used to design Medical Management programs and to enhance consistency in services provided and reporting.
Outlines and defines the key components of Medical Management by building a comprehensive Care Management and Utilization Management program and provides examples of tools and strategies that can be used by CHRISTUS Health Plan in designing programs to effectively meet the needs of beneficiaries with complex and special needs.
Responsible for State and Federal regulatory reporting, contractual compliance, oversight of related delegated vendor functions, in addition to Medical Management operations, network supervision and staff management of Care Management reviews, Case Management, and coordination of linked and carved out service functions.
The Director of Medical Management and Population Health Management is further responsible for ensuring all functions are operating in accordance with the organization's mission, values and strategic goals are focused on continuous improvement; and are provided in a manner that is responsive and sensitive to the needs of the CHRISTUS Health patient population served.
The Director of Medical Management and Population Health Management will be responsible for building a comprehensive care management plan and aligning the work force to the appropriate initiatives and measures.
Instrumental in working with key partners within the CHRISTUS Health Plan and CPG delivery system to represent CHRISTUS Health Plan's Care Management initiatives and/or programs.
The position is also responsible for oversight of delegated clinical functions insuring that care determinations are managed and monitored appropriately.
Works collaboratively with executive leadership, medical directors, engagement services, operations, provider network, government products, project management and informatics to identify, develop, implement and monitor programs and processes.
The Director of Medical Management and Population Health Management is responsible for reporting program effectiveness to the Executive Team as well as the Board of Directors when appropriate.
Provide leadership support to Medical Management and Population Health projects related to CHRISTUS Health Plan, USFHP, Medicaid, CHIP, NM HIX, NM MA, and TX HIX lines of business as well as provider groups within CHRISTUS Health Plan.
Effectively establishes and maintains collaborative working relationships with the medical staff, management team and staff to achieve best practice outcomes, improve clinical performance and corrective action plan responses
Improves responsiveness and relations with all customers, including patients and their families, faculty and community physicians, other participating providers, affiliated health plans, staff, regulatory and accrediting bodies
Performs other duties as assigned.
Proven ability to understand Care Management, Utilization Management and Population Health Management trends and to develop initiatives designed to bend trend while insuring appropriate access to quality care.
Strong experience and demonstrated ability in understanding quality initiatives and developing/implementing quality management programs and analyzing both financial and quality data, focusing on continuous quality improvement, across multiple projects and multiple sites concurrently
Demonstrated ability to lead and motivate clinical and administrative teams to achieve specific objectives.
Ability to understand and analyze complex business problems and apply cost effective solutions. Strong critical thinking skills, ability to make tough decisions and prioritization skills required.
Demonstrated experience working with multi-disciplinary teams in and across functional and organizational boundaries.
Ability to foster adoption of clinical technology and care delivery support systems across a range of environments and clinical contexts for all clinical applications.
Demonstrated knowledge of managed care including understanding of the physician, provider, payer and employer perspectives.
Graduate of an accredited School of nursing program-Bachelor of Science in Nursing
Master of Science in Nursing or Equivalent
Ability to work well with diverse groups of individuals
Ability to deal sensitively and diplomatically with difficult situations
Experience and/or knowledge of computer systems, data collection, and data dissemination preferred
At least 6 years' experience in Utilization Management, Case Management and/or Quality Management
In-depth knowledge of the healthcare industry. Must possess a keen working knowledge of care management, utilization and quality management, procedure and diagnostic coding, and Electronic Medical Record (EMR) usage in ambulatory/outpatient and/or hospital settings.
Minimum (4) years' experience in a quality management program in a managed care/health plan, IPA, ambulatory care, or hospital setting(s).
Experience with Care Management and Transitional Care Management
Skill in the use of computerized systems and databases.
Ability to understand and follow research protocol and procedures and ability to analyze and interpret scientific data. Working knowledge of statistical analysis and reporting practices pertaining to quality improvement and program evaluation.
Strong communication, collaboration, influencing, teamwork, project and time
CHRISTUS HEALTH is an international Catholic, faith-based, not-for-profit health system comprised of almost more than 600 services and facilities, including more than 60 hospitals and long-term care facilities, 350 clinics and outpatient centers, and dozens of other health ministries and ventures. CHRISTUS operates in 6 U.S. states, Colombia, Chile and 6 states in Mexico. To support our health care ministry, CHRISTUS Health employs approximately 45,000 Associates and has more than 15,000 physicians on medical staffs who provide care and support for patients. CHRISTUS Health is listed among the top ten largest Catholic health systems in the United States.