The Population Health Associate plays a critical role in aligning Vanderbilt Health Affiliated Networkâs (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 populationâs 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 practiceâs goals and objectives to manage local population needs
Integration of behavioral health into care in alignment with the practiceâs goals and objectives to manage patient needs
Integration of patient engagement initiatives which may include Patient Family Advisory Councils in alignment with the practiceâs goals and objectives for patient and family engagement
Identifies practice process improvement opportunities and provides support by initiating PDSAâs 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
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 (EHRâs, 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
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; familiarity with regional providers and Vanderbilt health facilities. 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.
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.
Vanderbilt University Medical Center is a comprehensive health care facility dedicated to patient care, research, and biomedical education. Our reputation for excellence in these areas has made us a major center for patient referrals from throughout the Mid-South. Each year, people throughout Tennessee and the Southeast choose Vanderbilt University Medical Center for their health care because of our leadership in medical science and our dedication to treating patients with dignity and compassion.The mission of Vanderbilt University Medical Center is to advance health and wellness through preeminent programs in patient care, education, and research.