Manager, Transitional Care Management Pop Health

Employment Type: Full time Shift: Day Shift Description: GENERAL SUMMARY AND PURPOSE: The Population Health and Transitional Care Manager of Population Health is a key contributor to the Saint Alphonsus Medical Group (SAMG) Population Health Team. Reporting directly in partnership with the Director of Quality and Population Health and in collaboration with the Executive/Medical Director of Population Health, this position leads a highly skilled RN team to improve community health and wellbeing during a patient’s transitional time post-acute inpatient or Emergency Department (ED). The population health team strives to reduce health disparities and inequities, reduce re-admissions, reduce avoidable hospitalizations, address social health influencers in order to improve patient outcomes and reduce total cost of care. This opportunity could be a hybrid position where one should be on-site on Mondays, Tuesdays and Wednesdays. The position will be located across the street from the Boise Regional Medical Campus. SKILLS, KNOWLEDGE, EDUCATION AND EXPERIENCE: Must possess a Registered Nurse License. Bachelor of Science degree in nursing required with 3-5 years or more years of related experience. Master's preferred. 3 years of leadership/supervisor/manager experience required. 2 -3 years of care/case management experience strongly preferred Certified Case Manager (CCM) preferred and or highly encourage completion national certification of case manager (CCM) exam in 1 year of hire date. Quality (STARs/HEDIS). ESSENTIAL FUNCTIONS: Knows, understands, incorporates, and demonstrates the Organizational Mission, Core Values, and Vision in behaviors, practices, policies and decisions. Utilizes a working knowledge of “wrap around” transitional care management care coordination model and team-based care initiatives to reduce Emergency Room/Department utilization, and Inpatient readmission. Confidently works at the top of licensure and encourages team to utilize critical thinking skills to recommend evidence-based care and promote team-based care with primary care provider’s and clinic staff; will work closely with the population health transitional care manager lead. Works collaboratively with the Director of Quality and Population Health to support successful execution of established objectives (financial and non-financial) for population health management inclusive of chronic care protocols, identification of most at risk vulnerable patient populations, patient registry, transitions of care, and care coordination workflows to address social influencers and medical needs to improve health outcomes. Partners with care manager teams across the ecosystem of the inpatient setting, the Saint Alphonsus Health Alliance, Community Health and Wellbeing divisions of SAHS, and/or vendors to support care/case management for an effective continuity of care experience for the SAMG community of patients and providers. Makes clear and concise presentations to clinic staff, provider meetings as needed; must have excellent verbal and written communication. May partner to provide presentations in partnership with Director of Quality and Population Health. Responsible for the day-to-day delegation of assignments appropriately while maintaining outreach coverage accountability. Use EPIC and other data reporting to evaluate efficacy of the population health and or patient outcomes. Provide data efficacy reporting to Directors, and leadership at monthly meetings. Responsible for hiring, orienting, supervising, coaching, developing the population health RN team. Responsible for monthly chart record “spot” audits for supportive performance improvement opportunities in documentation, care coordination, or other population health opportunities Able to audit with factual objectivity and evaluate root cause analysis for process improvement initiatives. Determines staff competencies required to provide quality care and services in area of responsibility. Completes performance plans and evaluations in a timely manner for staff. Facilitates the resolution of problems and conflict by encouraging decision making by those responsible, remaining objective, respecting feelings, leans into “positive intent” by soliciting facts and multiple perspectives to each new idea. Implements corrective action plans as necessary. Able to create or enhance the development of standard operation procedures (SOPs) as needed. Utilizes effective communication skills to lead teams, identify strengths, promote colleague career growth. Comfortable defining and communicating clear expectations, attendance, effective communications, codes of professional standards, and accountabilities with colleagues. Promotes teamwork by keeping team informed in “huddle” meetings, participating in group decision making, working to accomplish team objectives, and by soliciting encouraging feedback to improve workflow. Encourages setting up team for success and assists with developing skills and providing educational opportunities. Effectively builds and maintains clinic team/provider relationships to promote effective collaborative team-based care population health programs and initiatives. Highly encouraged and welcomed to bring new innovative ideas or services to help develop the organizational strategic and tactical plans in concert with planning processes lead by SAMG Senior Leadership. In collaboration with Executive Medical Director, develops short- and long-range plans to support the mission of the organization, the strategic plan, and departmental and team goals and objectives. Promotes continuous improvement through innovation and work redesign. Maintains a working knowledge of laws/regulations; the SAMG/Trinity Health Integrity and Compliance Program and Code of Conduct; as well as other policies and procedures in order to ensure adherence in a manner that reflects honest, ethical, and professional behavior. Work Location will be in the SAMG senior leadership offices, Boise, ID Spends 10 - 25 % of time traveling between SAMG clinics. Colleagues of Saint Alphonsus Health System enjoy competitive compensation with a full benefits package and opportunity for growth throughout SAHS and Trinity Health. Visit www.saintalphonsus.org/careers to learn more about the benefits, culture and career development opportunities available to you at Saint Alphonsus Health System. Saint Alphonsus and Trinity Health are committed to promoting diversity in its workforce and to providing an inclusive work environment where everyone is treated with fairness, dignity and respect. We are committed to recruit and retain a diverse staff reflective of the communities we serve. Saint Alphonsus and Trinity Health are equal opportunity employers and prohibit discrimination against any individual with regard to race, color, religion, gender, marital status, national origin, age, disability, sexual orientation, or any other characteristic protected by law. Our Commitment to Diversity and Inclusion Trinity Health is one of the largest not-for-profit, Catholic healthcare systems in the nation. Built on the foundation of our Mission and Core Values, we integrate diversity, equity, and inclusion in all that we do. Our colleagues have different lived experiences, customs, abilities, and talents. Together, we become our best selves. A diverse and inclusive workforce provides the most accessible and equitable care for those we serve. Trinity Health is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, status as a protected veteran, or any other status protected by law. Trinity Health is one of the largest not-for-profit, faith-based health care systems in the nation. Together, we’re 121,000 colleagues and nearly 36,500 physicians and clinicians caring for diverse communities across 27 states. Nationally recognized for care and experience, our system includes 101 hospitals, 126 continuing care locations, the second largest PACE program in the country, 136 urgent care locations, and many other health and well-being services. Based in Livonia, Michigan, in fiscal year 2023, we invested $1.5 billion in our communities through charity care and other community benefit programs. For more information, visit http://www.trinity-health.org. You can also follow Trinity Health on LinkedIn.