The Quality and Population Health Manager is a dynamic role that supports quality and Population Health at Siskiyou Community Health Center (SCHC). This role works collaboratively with others to improve health and overcome social barriers for patients, supporting better outcomes for patients and families. This role oversees both the Population Health and Community Health Worker (CHW) teams. The Quality and Population Health Manger works to improve performance outcomes and supports success in value based payment. They ensure effective integration of Community Health Workers with clinical teams so that CHWs can actively engage with patients to provide navigation, connections, and support.

DUTIES and RESPONSIBILITIES:

· Supports to the CQO in implementation and execution of the Quality Assurance and Improvement Plan.

· Oversees the daily operations of the Population Health Team and CHW Team.

· Coordinates and conducts performance appraisals for CHW and Population Health team members, monitoring progress of mutually agreed upon goals.

· Monitors and evaluates team performance through check-ins and case review.

· Creates an environment of coordination and collaboration, both internally and externally.

· Monitors caseloads of all CHWs, analyzing reports, monitoring effectiveness and progress towards goals.

· Ensures appropriate onboarding and ongoing training of team members.

· Provides or ensures reflective supervision for CHW employees.

· Coaches and mentors the CHW team to support effective referrals, warm connections, and engagement with patients.

· Supports integration of CHW and Population Health team with care teams working in clinics.

· Leads and coordinates activities required for grant reporting, as applicable.

· Utilizes and maintains an organized system of clinical documentation to track and analyze outcomes, support coordination of care, and capture needed elements for billing.

· Oversees clinical records and documentation practices of team members, ensuring best practices, professional ethics, and program requirements adherence.

· Oversees care coordination functions, in particular those relating to transitions of care and Social Drivers of Health (SDoH).

· Seeks opportunities to adhere to evidence-based care standards for chronic disease treatment and reducing gaps in routine preventive health services and screenings.

· Supports the CHW program in meeting quality and performance standards and indicators for all grants, as applicable.

· Facilitates and manages improvement projects and activities to improve quality of care.

· Participates in, coordinates, and facilitates internal and external meetings related to Quality Improvement (QI) activities and projects to support quality assurance or improvement.

· Prepares and utilizes quality reports and dashboards.

· Ensures monitoring data and patient survey reports collection and preparation for organizational analysis.

· Implements projects and strategies to support optimal success in Value Based Payment performance.

· Researches best practices and conducts staff shadowing, chart reviews, and chart audits to develop and revise written workflows, guidelines, and procedures as needed to improve Population Health and quality.

· Supports state and federal quality audits, in particular Patient-Centered Primary Care Home (PCPCH), Health Resources and Services Administration (HRSA), and Federal Torts Claim Act (FTCA).

· Maintains current knowledge of new or updated quality metrics related to PCPCH, Uniform Data System (UDS), HRSA, Coordinated Care Organizations (CCOs), Oregon Health Authority (OHA), and Medicare Advantage and supports compliance with requirements, audits, and applications.

· Communicates identified opportunities for improvement appropriately within the team and organization.

· Maintains compliance with grant-funded requirements, including program policies and procedures and programmatic changes, as applicable.

· Supports the provision of culturally responsive services that promote principles of fairness and belonging within a diverse service population.

· Works to address SDoH and support access to services for SCHC patients.

· Supports overall care coordination and barrier reduction for SCHC patients.

· Completes other duties as assigned.

QUALIFICATIONS, EDUCATION and EXPERIENCE:

1. Bachelor’s degree (preferred) in Health, Social Services, Behavioral Health, Nursing, Healthcare Administration, or applicable related work experience or high School diploma or GED considered with requisite experience.

2. Minimum three years’ experience in a healthcare setting preferred.

3. Minimum of one years’ experience working with an Electronic Health Record (EHR).

4. Experience with low socioeconomic status, at-risk families, and Medicare and Medicaid in a community setting is desirable.

5. Understands the cultural and socioeconomic issues of the local community.

6. Experience managing employees.

7. Proof of current CPR certification or ability to obtain one in 30 days.

8. Proof of current unrestricted Oregon driver’s license, comprehensive automobile insurance, and a safe driving record.

REQUIRED KNOWLEDGE, SKILLS and ABILITIES:

1. Excellent communication skills, including the ability to clearly communicate and apply policies and procedures to solve everyday problems and deal with a variety of situations.

2. Experience with data analysis and reporting.

3. Strong computer skills. Working knowledge of Microsoft Word and Excel.

4. Skills and experience in working with practice management software preferred.

5. Strong problem-solving skills, including the ability and experience to review and analyze data and information, recommending actions, which support clinic goals and objectives.

6. Effective customer relations skills, demonstrating the ability to work with diverse groups in a stressful environment, displaying an understanding of group dynamics.

7. Demonstrated organizational skills and effective use of time.

PHYSICAL DEMANDS:

Sitting at computer station for long periods.

HAZARDOUS CONDITIONS:

· Minimal exposure to infectious diseases.

WORKING CONDITIONS:

· Position is 90% office based and 10% in the community or patient facing.

· Occasional evening or weekend work required.

· Periodic state and national travel.

MACHINES, EQUIPMENT, TOOLS and SUPPLIES USED:

· Computer, printer, calculator, fax machine, copier, multi-line phone system, private automobile, and/or cellular phone.