Health Population Care Manager

Population Health Care Manager will work with Cabarrus Rowan Community Health Centers, Inc.  (CRCHC) patients and staff to stratify patient population according to risk to effectively and efficiently manage chronically ill patients in all CRCHC panels. This collaboration with physicians and practice staff will drive improvement in clinical measurement outcomes and patient outcomes to promote the highest standards of quality for CRCHC patients.   

Minimum Qualifications

Ability to communicate in English accurately and concisely both verbally and in writing. Interacts in a professional and patient-centered manner with patients.  Able to work cooperatively with internal staff to deliver safe, effective, quality care to all patients. Able to plan, prioritze and complete assigned tasks with a high level of accuracy.  Ability to work well under time constraints while maintaining accurate records

·         Experience: 2 years of related work preferred, Care Coordination, Mental or Behavioral Health experience preferred.

·         Additional skills required: CMS Stars, PCMH, and HEDIS clinical quality measures and healthcare metrics knowledge required. Proficient in data management and reporting. Clinical Experience is highly desired. Strong project management skills, which include clinical data abstraction, organizational, analytical skills and process improvement. Ability to understand and provide thoughtful input about strategic opportunities. EMR experience, Athena.

·         Travel required- Rowan County and Cabarrus County

• Additional skills: Population health management database reporting experience, i2i Population Health software. Managed Care experience leading a team of care coordination and building out, operationally, a managed care program.

Education: Registered Nurse, or Licensed Clinical Social Worker (LCSW)

Certification(s)/Licensure: None

Physical Requirements:

The physical demands described here represent those that must be met by an employee to successfully perform the essential functions of this job.

·         Continuous walking, standing and moving about.

·         Frequently bends, kneels and crouches.

·         Frequently lifts, pushes or otherwise moves and positions patients or other objects, exerting up to 50 lbs.

·         Repetitive movement of hands and fingers – typing and/or writing.

·         Talk and hear.

·         Possible exposure to hazardous fumes, airborne particles, toxic/caustic chemicals, bodily fluids, etc.

Key Responsibilities

1.       Work with clinical and administrative staff to develop creative processes to proactively manage high risk patient populations

2.       Oversee CRCHC Care Management program with the support of the Care Coordinator Supervisor.

3.       Oversee the administrative support of the Health Coach Program.

4.       Ensure the completion of comprehensive assessments, risk assessment and regular care coordination of all moderate to high-risk patient populations.

5.       Provide and/or support data management for specific patient populations for care coordination and case management.

6.       Conduct and/or coordinate health risk assessments of CRCHC patients, which includes social determinants of health (psycho-social, physical, medical, behavioral, environmental, and financial parameters, etc.)

7.       Analyze, develop, and implement improvement plans from clinical quality performance reports from various insurance plans, clinical integrated networks, and other like organizations

8.       Identify underlying issues that may contribute to gaps in clinical quality performance; work with practice staff to close gaps and improve individual care team performance

9.       Through partnerships with patients, caregivers/families, community resources, and their care teams, coordinate appropriate interventions, cost effective delivery of quality care and services to achieve high-quality care that is patient-centered

10.    Generate reports and monitor patient adherence to plan of care and progress toward goals in a timely fashion. Facilitate changes as needed

11.    Implement effective Medicare Chronic Care Management program for all eligible CRCHC Patients.

12.    Manage Care Coordination staff and provide supporting data for Case Management/Care Coordination services.

13.    Oversee the care coordination services to all CRCHC patient panel in line with all State of NC Medicaid and third-party quality guidelines.

14.    Provides additional administrative support to all quality improvement department projects and initiatives.

15.     Support current incentive, regulatory, and certification requirements (such as Meaningful Use, PCMH and UDS) through documentation, participation in initiatives, and other activities as directed.

16.    Perform other duties as assigned.

CRCHC Core Requirements

1. Patient Centered Customer Service – Whether directly or indirectly, we work to support the delivery of an excellent patient experience to everyone served by the organization.
2. Caring and Compassion – We provide empathic comfort to those in distress and share kindness in all interpersonal interactions.
3. Respectful Communication – We communicate openly, honestly and without judgment while honoring everyone’s uniqueness and assuming the best of those with whom we interact.
4. Teamwork – We are members of a diverse interdisciplinary team working together to meet a common goal.
5. Accountability – We accept our individual and team responsibilities and we meet our commitments. We take responsibility for our performance and actions.
6. Customer Safety – We recognize and correct potential hazards to protect ourselves and our customers.

CRCHC provides comprehensive, high-quality primary health care to our patients regardless of ability to pay. As a Federally Qualified Health Center (FQHC), we provide health care to all members of our community, including low income, indigent, and uninsured patients who may not otherwise be able to afford health care via traditional sources. We screen potential employees to first ensure alignment with our core requirements followed by the requisite position skills set.  In doing so we need staff committed to this mission who do their best to live and work the characteristics of our core values as we strive to care for ever increasing members of the communities we serve.