Summary Description:
The Population Health Manager is responsible for establishing processes that support the National Committee of Quality Assurance (NCQA) and Healthcare Effectiveness Data and Information Set (HEDIS) requirements related to Population Health Management (PHM) preventive care services, disease management programs as well as identifying and reducing healthcare disparities. The Population Health Manager develops and coordinates evidenced based health management strategies, health education materials for all media types, execution of PHM, Nurse Advice Line (NAL) and Telehealth initiatives, products and services through continuous assessment of HEDIS outcomes and quality performance. The Population Health Manager evaluates new PHM products, finalizes contracts, oversees implementation and provides continuous vendor management. The Population Health Manager contributes to employer facing PHM reports. The Population Health Manager will support department leadership with NCQA and DMHC deliverables.
Representative Duties:
- Promote and adhere to WHA’s Privacy and Information Security Programs. Ensure and verify that all department Workforce Members attend and complete mandatory training. Inform department Workforce Members that WHA will take disciplinary action up to and including termination of employment or assignment with WHA for violation of these privacy and security policies, procedures, and regulatory requirements. Also, that strict adherence to the related laws, rules, regulations, policies, and procedures is considered an integral part of their job performance, and monitor compliance
- Support the Director with the development and implementation of the organizational plans, strategies
- Support CMO with annual budget process
- Review and analyze department actual performance against the targeted performance objectives leveraging company data applicable to the department, available KPI (Key-Performance Reports) and other available performance measurement resources
- Work collaboratively and cooperatively with department leaders to develop and implement supplemental plans and/or strategies to mitigate departmental performance gaps to stated business objectives and/or targeted KPI (Key Performance Indicator) results
- Support the Director with the process of aligning and documenting the department’s business priorities, goals and objectives on a quarterly and/or monthly basis, so as to achieve business targets as set forth in the annual business plan
- Interface and collaborate with departmental team members, as well as other functional area leaders, on special projects and/or towards the accomplishment of company-wide business goals, objectives and project deliverables
- Represent and effectively present functional area and/or departmental performance information, project updates and other miscellaneous information to a variety of internal and/or external organizations, business clients, consumers and/or the general public
- Support the Director with the development and maintenance of key-stakeholder relationships relevant to the department and/or the company
- Collaborate with Director on the departmental staffing plans and processes to support the effective execution of the departments and/or company’s business plans, strategies and initiatives
- Work collaboratively with Human Resources and the functional area team members to select, train, supervise, and effectively performance manage the department’s staff
- Maintain consistently high-performance standards for all direct reports and other team members by regularly communicating business updates, coaching, counseling, disciplining and completing timely performance evaluations in accordance with the company’s Human Resources guidelines and standards
- Support the Director with the development and implementation of population health strategies that address key SDOH (Social Determinants of Health) and health equity factors to develop organizational plans and strategies. Collaborate with internal teams and external partners to design Population interventions that reduce health disparities
- Manage the PHM budget and participate in the annual budget update
- Utilize claims, clinical, and community data to identify members for population health activities
- Work collaboratively with other internal and external sources to improve processes that affect clinical quality outcomes
- Research national benchmarks and best practices for clinical performance to condition clinical outcomes to establish overall health management programs, products, and services
- Oversee the design and development of member and provider newsletter publications and health education materials
- Develop newsletters and health education materials focusing on HEDIS driven measures
- Provide ongoing quality management and outcomes analysis for PHM NAL and Telehealth initiatives
- Analyze member data for identification of trends influencing member behaviors and barriers to compliance
- Develop the data tables and disease specific databases for PHM initiatives, working closely with internal departments and clinical rules that drive the stratification and intervention design and development
- Utilize tools for clinical applications from encounter/claims data (Cotiviti, Provider Intelligence tool, SCAN, or similar) in support of clinical activities for the department
- Develop and manage the policies and procedures associated with PHM NAL and Telehealth programs
- Conduct preventive health research and market analysis for health promotion programs, products and services to include wellness programs, preventive health, healthcare disparities and risk management initiatives, and interventions
- Prepare and submit report deliverables to corporate sponsors within contractual timelines
- Develop and coordinate implementation of PHM, NAL and Telehealth goals and objectives
- Work with medical groups to ensure a consistent, measurable, and cohesive approach to PHM programs
- Perform oversight activities for outsourced PHM, NAL and Telehealth services
- Develop vendor proposals, negotiate price points, and recommend build, buy, or partner options to support PHM, NAL and Telehealth initiatives. Oversee vendor performance, ensuring adherence to contractual quality, scope and utilization benchmarks
- Assure programs, products, and services comply with Health Insurance Portability Accountability Act (HIPAA), National Committee of Quality Assurance (NCQA) and Department of Managed Health Care (DMHC) and Centers for Medicare and Medicaid Services (CMS) regulatory requirements
- Execute program, product and service evaluations using performance audit tools, clinical care practice guidelines and defined process/analysis standards
- Assist with completion and distribution of request for proposals (RFP) for designated programs or services
- Maintain designated document materials and content for all media types
- Serve as a member of the Credentialing, UM and Quality Committees
- Perform other duties and special projects as assigned
Qualifications:
- Valid Registered Nurse (RN) License is required for this position and must be maintained for the duration of employment
- Bachelor’s degree in Nursing, Public Health, Healthcare Administration, or a related field is required. A master’s degree in a relevant subject area such as Nursing, Public Health, Health Administration or related field is preferred
- Minimum of 5 years’ experience in Population Health Management or a similar role in the healthcare industry
- Minimum of 3 years’ supervisory experience is preferred
- Strong understanding of healthcare policies, regulations, NCQA, HEDIS and trends related to population health
- Excellent analytical and problem-solving skills, with the ability to interpret and utilize data to inform decision making
- Evidence in developing and implementing population health programs and initiatives, with a focus on improving outcomes and reducing healthcare costs
- Intermediate computer skills, including electronic mail, routine database activity, word processing, spreadsheet, graphics, etc
- Must be able to speak, read, write, and understand the primary language(s) used in the workplace
Salary:
$120,000.00 -$140,000.00 Annually
Western Health Advantage is committed to providing equal employment opportunities to employees and applicants for employment on the basis of merit and without regard to race, color, religion, gender, sexual orientation, gender identity or expression, national origin, age, physical or mental disability, medical condition, genetic information, marital status, ancestry, military or veteran status, or any other basis made unlawful by federal or state law.
Western Health Advantage values and supports the unique talents and strengths that each employee brings to our organization. Collaborating with the best and the brightest means a dynamic, fulfilling work experience for you — and excellent customer service for our members.
- WARNING: Please beware of phishing scams that solicit interviews or promote work-at-home opportunities, some of which may pose as legitimate companies. Please be advised that Western Health Advantage will never ask you for a credit card, send you a check, or ask you for any type of payment as part of consideration for employment with our company. If you feel that you have been the victim of a scam such as this, please report the incident to the to the Federal Trade Commission by selecting the ‘Rip-offs and Imposter Scams’ option.’
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