Population Health Associate (PHA)

Job Summary

The Population Health Associate plays a critical role in aligning Vanderbilt Health Affiliated Network's (VHAN) mission by supporting physicians, providers and their practices as they apply population health strategies in the network . The Population Health Associate will successfully engage, monitor, and develop strategic relationships with VHAN providers to inform transformation of care delivery redesign and enable the achievement of the triple-aim: improved patient experience, improved clinical quality, and reduction in total cost of care. Travel is expected throughout the network to meet with physicians and practice teams to support clinical practice transformation.

Key Functions and Expected Performances

• Facilitates care coordination across the network, evaluates and make recommendations regarding population health management process and infrastructure.

  • Patient risk stratification to understand the population's disease burden and high-risk patient support

  • Ability to facilitate health promotion and disease prevention through care gap closure, disease and case management

  • Ability to track care plans and medication adherence

  • Processes to identify and manage patients as they access care throughout the care continuum

  • Integration of community resources to align with the practice's goals and objectives to manage local population needs

  • Integration of behavioral health into care in alignment with the practice's goals and objectives to manage patient needs

  • Integration of patient engagement initiatives which may include Patient Family Advisory Councils in alignment with the practice's goals and objectives for patient and family engagement

• Identifies practice process improvement opportunities and provides support by initiating PDSA's and other improvement methods/tools

  • Conducts routine assessments of practice operational and clinic functions, and recommend necessary changes

  • Tests and refine practice and population management workflows that support care delivery redesign (e.g., pre-visit planning for preventative screenings, daily huddles, follow up visits after discharge from emergency department or inpatient settings)

  • Leads in developing, planning and implementing new processes, procedures, and programs that will impact clinical outcomes

  • Provides education and training sessions for quality and process improvement

• Increases efficiency in care delivery by supporting the adoption and implementation of team based care concepts:

  • Team members across the network and within the practice working at top of license

  • Adoption of e-visits and group visits

  • Promotion of patient portals, 24/7 access to care team

  • Patient as care team member

  • Team communication

• Ensures the practice management system and EHR are optimized in support of the practice and its population management goals

  • Advises in ways to improve the use of the practice technology. This includes CPOE, patient portal, e-prescribing, accessing the quality reports and dashboards, registry reporting options, etc.

  • Plans, organizes and facilitates trainings for staff and providers, including training related to technology (EHR's, registries, etc.)

  • Supports providers in meeting the Advancing Care Information requirements for the MIPS program as applicable

  • Educates providers on HCC coding opportunities to ensure all clinical conditions codes are captured, documented and coded according to CMS guidelines.

• Employs project management skills to support practice transformation efforts

  • Works closely with VHAN value based program coordinators to ensure practice-specific timelines and milestones are met

  • Meets with practice/project team to plan and execute the improvement team agenda

  • Coordinates timely communication of assigned quality and process improvement initiatives to appropriate groups

  • Assures maintenance of project plans and records

  • Utilizes change management to drive performance and results

  • Facilitates the management or removal of barriers to keep teams on timeline target

• Utilizes creativity and principles of redesign when working with administrative and clinical leadership teams engaged in redesign of care systems

  • Serves as a mentor and coach to practice-level improvement teams

  • Demonstrates positive communication skills in working with providers and practice staff.

  • Utilizes effective coaching and training techniques specific to providers and practice staff needs.

  • Identifies early wins to build engagement and enthusias

  • Serves as a resource for the interpretation of standards applicable to operations and the conversion to value-base care

  • Collects, shares and employs best practices throughout the organization

  • Identify needs related to leadership, teamwork, & communication and provide target resources and/or training

Qualifications:

Bachelor's Degree (or equivalent experience) and 5 years clinical or related experience working with physicians, healthcare providers, and hospital administrators, to include mid-level administrative experience; Master's degree preferred.

Experienced at using data to set goals, influence stakeholders and measure progress

Comfortable working autonomously in a fast-paced, dynamic environment while maintaining focus on key goals.

Excellent organizational skills.

Excellent oral and written communication skills (i.e., public presentation skills).

Exceptional interpersonal communication and team-building skills.

Ability to manage multiple projects and activities on a routine basis, with minimal supervision.

Physician Practice Electronic Health Record and Microsoft Office experience required.

Preferred

Experience in practice re-design work including NCQA Patient Centered Medical Home (PCMH), practice transformation, quality improvement, accountable care organizations (ACO) development, ambulatory care setting, quality and efficiency metrics, and electronic health records highly recommended.

Clinical education/experience as an RN, LPN, or LCSW

Project management tools preferred. Willingness to learn new software applications.