The Director of Population Health (DPH) is responsible for the oversight, direction, and performance of the population health program at CommUnityCare (CUC) in pursuance of optimal health outcomes, sophisticated study of patterns of health determinants, and strategic health-impacting interventions. Working closely with the CMO and the quality council, DPH chairs CUC’s Population Health Committee and is responsible for creating functional strategies and specific, comprehensive objectives for the Committee’s various quality management teams in promotion of CUC’s strategic goals. DPH actively influences CUC’s high-performing care model through integration of key domains of population health including transforming healthcare, engaging community, and turning information into insight. DPH is a subject matter expert in both upstream and downstream influences on population health, including clinical and pre-clinical disease, as well as the external (social determinants of health) and internal (beliefs and lived experience) contexts to an individual’s health and wellbeing. In collaboration with data analytics, performance improvement, clinical, operations, nursing, and care management teams, DPH oversees development of action plans for enabling services to address social determinants of health, clinical care to address disease prevention and treatment, and behavioral health and skills building interventions for psychosocial empowerment. DPH supports the Associate Director of Population Health Management in their capacity overseeing population health interventions through care management, health coordination and coaching, and panel management. DPH reports to the CMO.
Essential Duties (at least 5 that are non-negotiable duties and are absolutely pertinent to successfully completing the job without accommodations):
• Maintain and manage the structure of the population health committee and cadence of progress.
• Advise senior leadership related to strategic direction of population health paradigm.
• Provide expert analysis and understanding of population-level data to guide action and policy.
• Monitor health outcomes including those within the quality management teams’ workstream.
• Identify patterns of health determinants using multiple data sources, internal and external to the organization.
• Serve as subject matter expert on interventions to positively impact health outcomes and patterns of health determinants.
• Present population health data and functional interpretation to organization leadership to guide care model and organizational strategy.
• Oversee work prioritization and performance improvement as related to population health.
• Oversee and develop population health informatics systems, including population health management and data analytics tools, to support organization strategic goals.
• Chairs the Population Health Committee.
• Actively participate in an ongoing dialogue with fellow Quality Committee Chairs and members of the QI Council in pursuit of strategic goals.
• Facilitate integrated work of data analytics, quality and performance improvement, clinical/nursing/operational leadership to improve health equity, quality outcomes, workforce wellbeing, patient experience, and resourcefulness.
• Develop and institute performance improvement metrics and processes and tools focused on a high performing, high quality service delivery model.
• Track and oversee quality team-based, population health service delivery, inclusive of multi-disciplinary care coordination.
• Promote and advise team-based care practices and patient-centered medical home frameworks.
• Communicates and promotes population health informatics to clinical staff, senior leadership, and any other designated individuals or groups.
• Provide expert advice in empanelment strategies and registry usage.
• Use refined patient complexity stratification to guide patient- and population-level health interventions, as well as staffing profiles for health delivery practices.
• Cultivate effective community partnerships that advance population health.
• Establish, in collaboration with multi-disciplinary leadership, high-performance, comprehensive enabling services.
• Advise on and promote gold-standard clinical workflows in pursuance of high performance and optimal outcomes.
• Collaborate with other health care organizations, including providers and payers, to provide comprehensive, integrated services, which may include organizing care management for patient populations.
• Develop and implement budgets, policies, and procedures that promote the desired population health program framework.
• In collaboration with clinical operations, nursing and training partners, promote excellence in medical education among all learners.
• Collaborate with operations and finance leadership to ensure resourcefulness of the department, inclusive of access and quality measures.
• Collaborate with broader leadership to advance service excellence and optimize patient experience.
• In collaboration with Human Resources and Operations, recruit, hire, and train appropriate staff.
• Serve as active participant of clinical leadership committees and meetings as delegated by the CMO.
• Perform other duties as assigned.
• High level of skill at building relationships and providing excellent customer service.
• Interpersonal savvy and influence skills in managing difficult clients and patients.
• High level of problem-solving skill to better serve patients and staff.
• Strong attention to detail and accuracy.
• Ability to utilize technology/computer for data entry and information retrieval. Experience with statistical software, Excel and PowerPoint.
• Ability to manage multiple responsibilities and emergency situations successfully.
• Excellent verbal and written communication skills.
• Ability to implement and evaluation operational and emergency situations successfully.
• Demonstrated understand of and/or experience working in a patient centered medical home (PCMH) environment.
• Demonstrated understanding and/or experience working in an integrated delivery environment.
• Maintaining ethical and professional standards as defined by the organization.
• Knowledge of health and human services environment trends and changes. Knowledge of local, state, and federal regulations and laws governing health and human services activities.
People Management/Department Management/Business Unit Management:
• Supports, leads and models the vision, mission and values of CUC.
• Works in tandem with the Health Center’s practice and clinical leaders to ensure a collaborative team-oriented environment.
• Serves as the champion for Value Based Care initiatives and other initiatives that may impact the operations of CUC and/or the quality of patient care.
• Leads and motivates the team members under his/her supervision; uses effective performance management processes.
Performs objective annual evaluations of all direct reports, as applicable.
• Assesses learning needs, develops competency plans and provides opportunities for learning for direct reports.
• Participates in departmental and interdisciplinary committees, which influence or determine policies affecting population health practices.
• Develops and maintains favorable internal relationships, partnerships with co‐workers, including clinical managers, clinical support staff, providers and business office staff.
MINIMUM EDUCATION: Master’s Degree in Public Health, Business Analytics or related field.
STRONGLY PREFERRED EDUCATION: RN or PA or MD/DO degree from an accredited educational institution
MINIMUM EXPERIENCE: 5 years in leadership/mentorship including epidemiology and/or clinical informatics.
STRONGLY PREFERRED EXPERIENCE: 2 years of clinical experience
Active and unrestricted State of Texas License for the appropriate medical degree or the ability to obtain one within the first six (6) months of employment.