Population Health Manager

CCI Health Services, a Federally Qualified Health Center (FQHC), is a community-based organization that provides comprehensive care to community members regardless of their ability to pay. At CCI, we empower patients to partner with staff for an unparalleled healthcare experience. Through integrated teams in a learning environment, we deliver high-quality, affordable care to every patient during all stages of life.

CCI has 8 locations in Montgomery County, and 2 locations in Prince George’s County, with extensive services that include: adolescent and adult primary care, pediatrics, dental, behavioral health, family planning, Centering®, women’s health, refugee health, infectious disease, HIV Treatment, nutrition counseling, and more. CCI Health Services is more than just a doctor’s office. It’s medical care grounded in community service. Since 1972, CCI has been striving to create a more equitable health care experience for local communities made vulnerable by social, economic, and cultural barriers.

Position Summary: Population Health at CCI speaks to the systematic process of utilizing data on patient populations to design targeted interventions for better health outcomes at lower cost, with a better care experience. This position serves to manage CCI’s value-based care operations. The role will serve as a key facilitator and partner to CCI departments, providers, provider leadership, care teams, and practice staff that manage member populations in value-based contracts toward improvements in the ’Quadruple Aim’ of better outcomes, lower costs, and an improved patient and clinician experience.

Essential Functions:

• Support the performance of providers under value-based contracts by integrating analytic insights, technical solutions, operational policies, and clinical programs into provider and care team workflows and processes

• Build dependable, engaging relationships with CCI departments, providers, provider leadership, care team, and practice staff to drive value-based care delivery processes and services

• As central coordinator to CCI departments, provider leadership, and partnering payers, periodically present VBC performance dashboards tied to metrics in the following domains:

          o Quality performance (HEDIS; UDS; Joint Commission; PCMH; MDPCP)

          o Efficiency performance (utilization management) o Clinical documentation quality (risk adjustment; coding practices)

          o Patient engagement (AWV completion rate; chronic disease management; CAHPS) o Referral network optimization

          o The total cost of care

• Review provider/practice-level metrics and trends, and present member-level risks and improvement opportunities to providers and provider leadership

• Co-develop action plans related to the presented opportunities and periodically report findings/progress to CCI committees and/or leadership

• Through periodic provider meetings, drive awareness, education, and recommendations to utilize appropriate value-based care resources, such as care management and high utilizer programs

• Perform other duties as assigned, including: o Assist Executive Team with management of CCI value-based care initiatives

          o Participate in CCI committees to develop synergies for CCI value-based care initiatives o Participate in vendor discussions to drive optimization of solutions tied to value-based care

          o Serve as CCI point of contact for value-based care matters

          o Keep abreast of current industry, market, and policy landscape and brief CCI stakeholders appropriately

• Supervision Requirements

         o Provides supervision and management to population health team including but not limited to population heath coordinator positions.

Knowledge of Job:

• High degree of autonomy, professional relationships, and data analytical skills.

• Knowledge and understanding of contract requirements with the Department of Health and Human Services.

• Medicaid waiver criteria, including but not limited to eligibility for the state of Maryland.

• Non-Medicaid CCI plans, levels of care and service definitions.

• CCI contracts with the Maryland Department of Health, Managed Care Organizations, and other value-based contracts for which CCI is responsible.

• Clear, concise, and appropriate verbal, written and electronic communication.

• Good communication skills, ability to engage, and present in large group settings.

• Effectively implement new initiatives and able to adapt to rapid changes.

• Knowledge and understanding of various software/ platforms used within the Population Health team. • Federal and state confidentiality requirements.

• Corporate compliance requirements.

• CCI Policies and Procedures.

Knowledge, Skills, and Abilities:

• 3+ years of experience in population health management, practice management, quality/performance improvement, practice transformation, change management, provider engagement, or project management strongly preferred

• 3 years’ experience with an electronic health record required;

• Experience managing projects in health care quality improvement and management, performance improvement, and/or practice transformation required;

• Experience with Electronic Health Records (EMR) and Population Health Systems;

• Experience with eClinicalWorks strongly preferred;

• Familiarity with medical terminology, ICD-10, and CPT coding strongly preferred;

• Intermediate to advance analytic skills and knowledge of research methods, data collection, and analysis preferred;

• Strong working knowledge of Microsoft Office applications required;

• Ability to understand the principles of CMS, HEDIS, NCQA, and Health Plan Quality Standards required;

• Detail-oriented, excellent proofreading and editing skills preferred;

• Ability to work with multidisciplinary staff with diverse backgrounds required;

• Ability to adapt to constantly changing community health care field environment required

Education:

• Required - High school diploma or equivalent.

• Preferred - Bachelor’s or Associates degree in healthcare, nursing, business administration, or related field.

Work Experience:

• Required - High school diploma with 7 years of related healthcare experience including 2 years of supervision or management experience; OR

• Bachelor’s degree with 3 years of related healthcare experience including 2 years of supervision or management experience.

• Preferred - Supervisory or Management experience in physician/hospital clinic operations, inpatient services, case management, homecare/hospice, public health, performance improvement or population health.