Director of Population Health

Job Description

Job Description

Established in 1980, the Greater Lawrence Family Health Center (GLFHC) is a multi-site mission-driven non-profit organization employing over 700 staff whose primary focus is providing the highest quality patient care to residents throughout the Merrimack Valley. Nationally recognized as a leader in community medicine (family practice, pediatrics, internal medicine, and geriatrics), GLFHC has clinical sites throughout the service area and is the sponsoring organization for the Lawrence Family Medicine Residency program.

GLFHC is currently seeking a Director of Population Health to join our team. The Director of Population Health (Director) at Greater Lawrence Family Health Center, (GLFHC), works under the leadership and direction of the Vice-President of Nursing and Clinical Support Services and in close collaboration with the Associate Vice-President of Clinical Integration, designated leadership at Community Care Cooperative (C3) and Community Partners (CPs) providers. In this collaborative leadership role, the Director will also interface with key GLFHC leaders in Quality, Clinical, Nursing, Analytics, Finance, Compliance and Operations in order to advance the goals of the population health division and broader GL strategic outcomes. The Director will be responsible for developing and implementing integrated models of care management programs and contribute to the development of GLFHC’s strategies that improve population health outcomes, the member and provider experience and lower the cost of care working within a value based care model. This role requires expertise in a systems approach to problem solving, using critical thinking skills and knowledge of community resources to plan and coordinate care. Areas of functional responsibility include ACO related care management, care coordination, CP Program oversight, community outreach, disease management, clinical integration with PCMH teams and the development of prevention & wellness programs. The Director will leverage data analytics to inform clinical program design and cost reduction opportunities. The Director demonstrates the highest level of professionalism and promotes an environment of teamwork and collaboration, including serving as a role model for others.

Job Responsibilities:

• Provides oversight to the care management team and ensures all team members are clinically integrated into local GLFHC practices and their role is optimized on the PCMH team
• Works in collaboration with members of the CSS division to ensure alignment with Social Determinants of Health (SDOH) strategies and grant funded care management programs
• Align behavioral health care management strategies with the Behavioral Health clinical service line and engages the BH clinician leader in reviewing complex cases
• Actively collaborates and engages site Medical Directors, other clinical leadership and Chief Medical Officer to ensure physician involvement, as appropriate, in clinical initiatives.
• Uses data analytics to evaluate and adapt the delivery of care management program based on the needs of patient populations
• Ensures coordination of care coordination activities with CPs and other community based services organizations and government funded programs
• Utilizes population health value-based data analytics to enhance the delivery of care coordination, complex case management, transitions of care and care coordination activities and new program development opportunities based on patient risk profiles
• Oversees population health coordinator functions including developing a framework for identifying and closing care gaps within the patient population as informed by data analytics
• Monitors key care management performance indicators related to patient caseloads, patient engagement, graduation rates and other process measures
• Oversees the CP program manager and ensures compliance with ACO contract requirements
• Incorporates a health equity lens in the design of key population health initiatives, including appropriate data collection and recommendations to address disparities and identify and solution for member barriers to care
• Ensure special initiatives such as SDOH, flex benefits, Care Needs Screening process are fully integrated into the care management workflow.

Qualifications and Experience:

• Current Registered Nursing licensure in the state of Massachusetts
• RN, BSN required. Advance degree in related area (business, clinical) highly desirable
• Certification on Case Management (CCM) highly desirable
• Five years or greater clinical experience in related field
• Five years or greater management experience
• Minimal five years of managed care experience supervising care management teams
• Working knowledge with performance dashboards and analytic functions
• Demonstrable prior experience overseeing care management functions and working in value based contracts
• Demonstrable leadership experience that demonstrates collaborative leadership, complex problem solving, stakeholder management, critical thinking and conflict resolution
• Ability to lead multi-disciplinary teams and effectively manage high impact initiatives through the deployment of cross functional improvement teams
• Effective communication skills, including ability to engage teams in problem solving and driving key outcomes
• Experience working in regulated practice environments, including the ability to interpret regulation and audit operational performance (documentation, policy adherence, etc.)
• Confident autonomous leader with strong interpersonal skills and proven ability to work in a matrixed model where stakeholder engagement is critical
• Strong organizational skills with ability to prioritize and multi-task as needed
• Working knowledge of excel, PowerPoint, and Visio
• Demonstrated experience working with diverse patient populations and workforce.

GLFHC offers a great working environment, comprehensive benefit package, growth opportunities and tuition reimbursement.