Clinical Integration & Population Health Administrator

About the Role

Reporting to the Chief Medical Officer, the Clinical Integration Manager is part of a multidisciplinary team driving clinical transformations towards value-based care delivery.

Responsibilities

• Develop strategies to achieve the quadruple aim; supervise all personnel pertaining to population health management (PHM) and clinical quality improvement (CQI) programs.
• Oversee the administration of care coordination programs, training, and care management staff.
• Develop workflows and protocols designed to guide team activities, ensuring alignment with the tenets of Patient-Centered Medical Home (PCMH).
• Direct the design, implementation, and evaluation of standardized electronic systems and resources for care coordination.
• Provide ongoing training to staff on evidence-based intervention strategies, care planning, and related care management delivery methodologies.
• Measure clinical care outcomes through data compilation, analysis, and communication of results.
• Maintain population health programs, including PCMH and chronic disease programs (e.g., diabetes, obesity, hypertension), and support provider relationships to improve internal communication related to system initiatives.
• Provide analytical support to senior leadership to identify new opportunities that positively impact quality performance and reduce inappropriate utilization/medical spending.
• Sustain and expand PHM programs, including PCMH and chronic disease programs.
• Serve as the point of contact for all value-based programs, including PCMH, Advance Primary Care (APC), DSRIP, MU, and Merit-Based Incentive Payment Systems (MIPS).
• Supervise all programs and personnel pertaining to PHM, Care Coordination, and CQI, including case managers, care coordinators, Clinical Quality Coordinator, and Patient Navigator(s).
• Supervise clinical initiatives, including grant-funded programs such as AIMS, SUD-MH, and Case Management for population health/SBIRT/CCM.
• Responsible for ongoing PCMH reports and maintaining PCMH standards of care.
• Generate, review, and monitor reports pertaining to PCMH, APC, and VBP programs to guide team activities and ensure program goals are met, including UDS and CQI (including taking minutes).
• Conduct data analysis to identify trends and patterns related to care outcomes.
• Develop action plans to address negative findings and support workflow redesign to meet state and federal benchmarks.
• Work with clinical staff to implement streamlined and efficient workflow changes.
• Support practices’ utilization of available Care Management programs.
• Aggregate and interpret operational and utilization data to identify populations that would benefit from new programs or interventions, as well as evaluate the effectiveness of clinical programs and specific interventions.
• Lead projects involving data analysis and performance improvement to implement system changes.
• Identify trends in data that may impact departmental performance and/or member outcomes, including those not actively monitored.
• Communicate actionable findings and provide recommendations to management.
• Develop policies, procedures, workflows, and protocols to guide team activities and support value-based programs.
• Provide administrative support for all CQI activities, including tracking, monitoring, and reviewing reports; entering results into dashboards; preparing CQI minutes and agendas; and assisting with PDSA cycles.
• Assist department heads in the development of QA/QI measures and annual targets.
• Conduct quarterly reviews of all measures for UDS and oversee HRSA-UDS reporting requirements to ensure timely submission of reports.

Requirements

• Bachelor’s degree required; Master’s degree (MS, MPH, MBA) or other licensed clinical degree (LPN, RN, NP, MD) preferred.
• 5-7 years of ambulatory care experience, preferably in a large medical group or healthcare system, with a focus on primary care.
• Experience managing projects in healthcare quality improvement, performance improvement, and/or practice transformation.
• Experience with programs and care models for high-risk individuals, as well as Medicaid/Medicare and uninsured populations.
• Evidence of essential leadership, communication, education, and counseling skills.
• Well-versed in social determinants of health.
• Ability to work effectively both as a team member and independently, managing timelines and multiple lines of business.
• Advanced proficiency in Microsoft Access and Excel required.
• Well-versed in Electronic Health Records (EHR) and reporting; eClinicalWorks (eCW) experience desirable.
• Excellent interpersonal, oral, and written communication skills.
• Strong organizational and project management skills.
• Excellent judgment and creative problem-solving skills.
• Proven track record of accountability and results.