SUMMARY:

Under the direction of the Chief Medical Officer (CMO), the Population Health Manager supports the mission of Community Access Network by implementing population health strategies and initiatives that improve health outcomes, enhance patient engagement, and increase access to comprehensive, integrated care. This position is responsible for the day-to-day management of the organization's population health programs that address chronic disease, preventive care, and social determinants of health. These programs include Community Health Workers, patient outreach and engagement, and case management services. The Population Health Manager provides direct supervision to the Patient Engagement Coordinator and the case management staff, while providing operational oversight of Community Health Workers (CHW) and outreach staff. The Population Health Manager uses information for systems and data to develop and implement workflows, policies, and performance standards that support quality improvement, Patient-Centered Medical Home (PCMH) recognition, population health management, and future reimbursement opportunities for CHW services. Working collaboratively with clinical and administrative leadership, this position uses data-driven approaches to close care gaps, increase patient volume and retention, ensure compliance with Ryan White Part C case management requirements, support quality outcomes, and strengthen CAN's role as an integrated healthcare provider serving the community.

ESSENTIAL RESPONSIBILITIES

Population Health Oversight

• Implements population health strategies and priorities established by the Chief Medical Officer.
• Coordinates day-to-day operations of CAN's population health programs.
• Develops operational work plans, workflows, and standard operating procedures that support population health initiatives.
• Monitors operational performance and recommends improvements to improve patient outcomes, and population health program efficiency.
• Supports organizational initiatives related to quality improvement, health equity, and integrated care.
• Coordinates implementation of new population health programs including population health pilot programs.

Leadership and Supervision:

• Provides direct supervision, guidance and evaluation of the Case Manager and Patient Engagement Coordinator.
• Ensures adequate management of assigned staff, including establishing workloads, prioritizing work assignments, establishing performance expectations, and evaluating employee performance; enforcing policies and procedures; resolving staff issues; assessing training needs, monitoring program performance; and evaluating the effectiveness of services.
• Oversee the effectiveness of care management, outreach and patient engagement functions carried out by CHWs and outreach workers through the Patient Engagement Coordinator.
• Ensures staff comply with organizational policies, clinical workflows, and documentation standards.
• Fosters a collaborative, culturally competent, and patient-centered team environment. Community Health Worker Program Leadership
• Develops, implements, and continuously improves CAN's Community Health Worker program, under the direction of the CMO.
• Provides operation oversight of the CHW program through the Patient Engagement Coordinator.
• Develops standardized workflows, documentation standards, productivity expectations, and performance measures for CHWs.
• Ensures CHWs are fully integrated into primary care, behavioral health, pharmacy, HIV and care management services.
• Oversees implementation of social determinants of health (SDOH) screening, resource navigation, health coaching, patient self0management support, and care coordination activities performed by CHWs.
• Develops policies, procedures, and documentation standards that support high-quality, evidence-based CHW services.
• Monitors program outcomes and social service referral completion and follow-up activities, recommending operational improvements using quality, utilization, and patient engagement data.
• Maintains knowledge of federal and state CHW reimbursement requirements.
• Collaborates with finance, billing, IT and clinical leadership to ensure workflows, documentation, coding, and reporting position CAN to bill for CHW services as reimbursement opportunities become available.
• Identifies opportunities to expand and sustain the CHW program through grants, partnerships, and reimbursement opportunities. Community Outreach and Patient Engagement
• Develops and implements an annual patient outreach and engagement plan that supports CAN's strategic priorities.
• Oversees outreach activities designed to educate the community about CAN's services, eligibility requirements, locations, hours, and integrated model of care.
• Develops targeted outreach strategics to increase new patient enrollment, improve patient retention, and strengthen utilization of existing services.
• Uses population health data, community needs assessments, referral patterns, and demographic information to identify priority populations for outreach.
• Coordinates outreach campaigns supporting preventive care, chronic disease management, behavioral health, HIV services, dental services, pharmacy services, and other organizational priorities.
• Develops and maintains referral relationships with social service agencies and other community partners addressing SDOH.
• Collaborates with the Director of Development and Partner Engagement to coordinate outreach activities, messaging, and community education efforts.
• Monitors outreach effectiveness using measurable indicators including new patient growth, referral sources, patient retention, completed appointments, and community engagement.
• Develops and implements, through the Patient Engagement Coordinator, a comprehensive patient education program that empowers patients to improve their health and effective manage chronic conditions.
• Ensures the Patient Engagement Coordinator plans, coordinates, and evaluates patient education activities delivered by CHWs, community partners and volunteers to improve health literacy, disease prevention, and self-management skills.
• Develops partnerships with community organizations and ensures, through the Patient Engagement Coordinator, the coordination of educational programs addressing SDOH, including nutrition, housing stability, transportation, financial wellness, employment, insurance coverage, legal resources, and other factors that influence health outcomes.
• Monitors the effectiveness of patient education activities through established performance measures and uses data to improve programming and patient outcomes. Ryan White Part C Medical Case Management
• Provides direct supervision to the Ryan White Part C Medical Case Manager.
• Ensures the medical case management program complies with Ryan White

HIV/AIDS

Program Part C legislative, regulatory, and programmatic requirements.

• Monitors case mangement documentation, eligibility determination, acuity assesment, service planning, referrals and follow-up activities to ensure compliance with HRSA reqirements and organizational policies.
• Ensures timely reporting, quality management activities, and performance measurement related to Ryan White Part C Medical Case Management.
• Collaborates with the Director of Nursing and Ryan White-funded nursing staff to improve retention in care, viral suppression, patient engagemnet, and access to supportive services.
• Develops and maintains policies, procedures and workflows supporting Ryan White Part C Medical Case Management.
• Collaborates with the Chief Financial Officer and finance staff to ensure Ryan White Part C medical case management expenditures for client support services purchased from exernal vendors, are appropriate authorized, documented, monitored, and mangement in accordance with grant requirements and organizational policies.
• Ensures staff receive appropriate training regarding Ryan White Part C requirements, documentation standards, and quality expectations.
• Supports HRSA site visits, program monitoring activities, corrective action plans, and continous quality improvement intiaties related to Ryan White Part C medical case management Population Health Analytics and Patient-Centered Medical Home (PCMH)
• Reviews population health dashboards and program performance reports to monitor outcomes, identify intervention opportunities, and direct quality improvement efforts. Collaborates with the Systems Optimization Coordinator regarding reporting needs and data analysis.
• Collaborates with the Systems Optimization Coordinator to support quality reporting initiatives and uses performance data to guide outreach and population health interventions.
• Under the direction of the CMO, is responsible for leading the initiative to become a Patient Centered Medical Home, as well as Distinction in Integrated Behavioral Health.

Learns and maintains expert level knowledge of the

NCQA PCMH

recognition requirements.

• Collaborates with other Leadership Team members to develop pilot projects and scale up population health initiatives at Community Access Network.
• Develops workflows and practice standards for population health, patient engagement, community health worker, and case management activities. Ensures assigned staff receive appropriate training and comply with established procedures.
• Collaborate with other departments to improve efficiency and care coordination. Communicates with staff and responds quickly to internal and external customers. Shares information and own expertise with others to enable accomplishment of goals and objectives.
• Values and incorporates the contributions of people from diverse backgrounds; demonstrates respect for the opinions and ideas of others.
• Other duties as assigned.

ROLE CLARIFICATIONS

• Population Health Manager o Owns operational workflows for outreach, CHWs, engagement, and case management.
• Systems Optimization Coordinator o Owns system workflows, EHR workflows, reporting workflows, and technology optimization.

QUALIFICATIONS

• Bachelor's degree required, master's degree in a relevant field preferred.
• Minimum 5 years of relevant experience in healthcare, continuous improvement and/or Population Health.
• 3 years staff supervision experience required.
• Demonstrated experience leading multidisciplinary teams or projects.
• Demonstrated proficiency in data management, analytics, and reporting required.
• Ability to work harmoniously and effectively with colleagues, patients and other stakeholders across the spectrum of diversity.
• Experience with electronic health records required, eClinical Works preferred.
• Strong organizational, communication, presentation and leadership skills.
• Broad understanding of community health centers, health inequities and evidence-based population health strategies.

REQUIRED VALUES

• Commitment to the vision of CAN; that everyone has a medical home providing optimal individual and community wellness. Work collaboratively, respectfully, and effectively with others and encourage open expressions of ideas and opinions.
• Practice cultural humility, avoid making assumptions about the knowledge, behaviors, or values of patients.
• Develop and maintain positive supportive working relationships with patients, providers, community organizations, and others.

I Job Type:

Full-time Pay:

$52,416.00 - $64,064.00 per year

Benefits:

401(k) 401(k) matching Dental insurance Employee assistance program Health insurance Paid time off Professional development assistance Retirement plan Tuition reimbursement Vision insurance

Education:

Bachelor's (Preferred)

Experience:

Staff Supervision:

3 years (Preferred)

Work Location:

In person