Manager, Population Health

At NorthBay Health, the Manager, Population Health oversees a staff that includes Population Health RN Case Managers, Social Workers, Resource Specialists, Diabetic Educators, Licensed Vocational Nurses and other staff who are responsible for patient care coordination with the goal of reducing readmissions and frequent ED visits. In collaboration with the Care Management Director, the Population Health Manager will ensure that comprehensive care coordination efforts will be made on behalf of high utilizer and frequently readmitting patients to significantly reduce unnecessary hospital readmissions and unnecessary ED utilization. 

The Manager, in coordination with the Director, ensures optimal team performance and accountability for ensuring implementation of robust social work and care management interventions that ensure reductions in preventable ED visits and hospital readmissions. The population health manager ensures that program objectives, design and operations are closely aligned with organizational strategic objectives and performance metrics including but not limited to Vizient readmission reduction targets, reduced total hospital admission targets for capitated populations as well as readmission targets for population health performance incentive programs. 

The population health manager will identify key measures of success (e.g. readmissions, ED utilization and overall hospital admission rates), and implements key processes to maximize efficient resource utilization. They will assume overall responsibility for coordinating/managing patient centered care activities, and ensures cost effective, quality patient outcomes through the supervision of clinical/professional staff, and collaboration with medical staff, nursing, and support staff.  Ensures compliance with state/federal and other regulatory and accreditation body requirements. 

PRIMARY JOB DUTIES

Provides leadership and guidance while creating and sustaining an innovative environment that supports excellence in care management. This includes informed program development through the continuous assessment, planning, implementation and evaluation of programs and standards that support positive patient care outcomes. 

Responsibilities include:

• Implements effective team oversight to ensure continual robust care management and social work interventions to reduce unnecessary acute utilization in patient populations.

• Ensures team accountability and performance to meet key organizational strategic objects including reduced readmission rates and reductions in overall hospital utilization.

• Consistently tracks team productivity and team performance data to ensure key program objectives are being met. 

• Effectively makes adjustments in program workflows and program interventions as needed to ensure optimal program performance in meeting system strategic objectives. 

• Ensures that all team members are routinely visiting patients face-to-face both in the hospital and in the community (homeless shelters, SNFs, etc.) to ensure maximum patient engagement and effective care management program interventions. 

• Ensures effective implementation of the Enhanced Care Management program (EMC) and other community partnership initiatives. 

• Assures Care Management interventions are documented with the patient, family or other identified support, and members of the entire care team to meet patients’ needs.

• Acts as liaison to post-hospital care providers, health plans and community partners.

• Ensures that patients that are high risk for psychosocial/environmental negative impacts, receive timely, coordinated social services interventions

• Is flexible as a leader meeting organizational strategic objectives when priorities change.

• Performs duties as assigned. 

Departmental Operations

1. Supports organizational mission statement, values and goals and role models to staff and others

2. Develops and support departmental goals and objectives with input from staff that aligns with, and supports the organizational and divisional goals and objectives

3. Maintains a state of readiness for all accreditation activities

4. Actively tracks and reports on departmental performance including processes and outcomes related to medical necessity of hospitalization, length of stay, timely and appropriate utilization of services and the proactive identification and documentation of discharge planning needs

5. Delegates authority and accountability to Leads, clinical/professional staff for clinical practice and patient care decisions that are consistent with professional standards, regulatory agencies and organizational policies and procedures

6. Assures all staff are functioning at top of license or scope of practice

7. Identifies and communicates opportunities to improve the quality of care and services to the appropriate individual(s)

8. Supports and facilitates evidence-based practice

9. Maintains an ongoing departmental based Performance Improvement Plan and processes consistent with the organizational Performance Management Plan

10. Compiles and reports case management data and other key metrics for internal and managed care reporting, physician committees, etc.

11. Develops and implements department specific standards and policies and procedures that guide and support the provision of services

• Manage process improvement initiatives, develop and implement workflows and develop policies and procedures 
• Develop, maintain, and oversee training materials and programs for case management staff training needs 

Operations Management

1. Assures appropriate utilization of all available resources to provide quality, cost-effective and efficient services

2. Develops and implements case management programs, including intake or discharge planning, complex case management, and transition of care programs. Evaluates patient care data to ensure that care is provided in accordance with clinical guidelines and organizational standards

3. Accountable for departmental staffing plan to (delegates daily staffing to leads), include appropriate number and skill mix, activities of recruitment and retention, interviewing, hiring, firing, evaluating, counseling and educating with a strong emphasis on staff competency and staff development

4. Assures safe environment for patients, staff and visitors

5. Meets all deadlines

6. Prepares, monitors and effectively manages annual personnel, operating and capital budgets

7. Demonstrates effective problem solving and conflict resolution skills

8. Communicates budgetary information to Director of Quality and Care Management, the staff and to the Division

9. Effectively manages all projects from conception through successful implementation

10. Develops and maintains an effective change management process for the department, leading by example

11. Utilizes available information systems effectively

12. Ensures consistent, positive communication and customer relations throughout the department, leading by example

13. Recommends space and other resources as needed for the department

14. Participates in selecting outside sources for needed services

Human Resources Development

1. Provides mentoring and coaching to direct reports and in turn ensures that direct reports provide the same to their Teams

2. Facilitates professional growth and development of staff through identification of needs, provision of educational programs and evaluations of efforts

3. Coordinates programs with the use of internal and external resources that will facilitate and promote professional growth opportunities for the staff

4. Assures that staff achieves and maintains identified competencies related to their practice through such activities as orientation programs, evaluation process, certification programs, in services, training, etc.

5. Meets all organizational requirements regarding hiring, orientation, First Day Safety, competency documentation, annual performance evaluations, coaching, counseling, and disciplinary action

6. Meets all mandated training/education requirements

7. Meets all accreditation and regulatory requirements re: human resource management

Collaborative Relationships

1. Promotes collegial relationships and demonstrates an ability to interact with physicians and other care team members in a professional, respectful manner

2. Facilitates multi-disciplinary collaborative practice with other disciplines

3. Serves as a resource to educate all disciplines on care management processes and multidisciplinary care delivery

4. Encourages and participates in joint planning and program development with other care team members

5. Develops partnerships with providers and clients to achieve quality and cost management objectives

6. Participates in multi-disciplinary committees within the organization and the community

7. Promotes and supports standardization within the organization for like services, including policies, procedures, practices, equipment and supplies

1. Education:  Graduate from an accredited school of registered nursing. Bachelor’s Degree in Nursing or related Health Care field is required.  Master’s Degree in Nursing or related Health Care field is required or required to be in progress.  One of the degrees must be in nursing.

2. Licensure/Certification: Current and unencumbered California Registered Nursing License required. National certification on case management preferred. Certification must be obtained within 2 years of hire.

3. Experience: Three (3) years in Population Health management required. 1-2 years of progressive management experience with increasing scope of responsibility at supervisor level or higher. Experience effectively managing challenging high acuity high utilizer populations strongly preferred. Knowledge of CMSA scope of practice. Knowledge of CDPH, CMS conditions of participation, and Title XXII.

4. Skills: Demonstrated initiative, follow through and ability to work independently. Ability to synthesize population health data, including risk stratification, into targeted programs. Demonstrated results oriented management. Demonstrated effective project management skills. Excellent written and verbal communication and presentation skills. Must be able to deal with job-related stress, multiple projects and deadlines. Advanced computer skills (spreadsheets, graphs, tables, data and reports). Experience with MIDAS and Interqual/MCG preferred.

5. Interpersonal Skills: Demonstrates the True North values. The True North values are a set of value-based behaviors that are to be consistently demonstrated and role modeled by all employees that work at NorthBay Health. The True North values principles consist of Nurture/Care, Own It, Respect Relationships, Build Trust and Hardwire Excellence. 

6. Hours of Work:  Management exempt.  Works primarily M-F 8-5, however evenings and weekends required as driven by business need.

7. Compensation: $200k to $230k annually based on years of experience doing the duties of the role.  This position is bonus eligible.

At NorthBay Health, we are guided by our values: Nurturing Care; Own It; Respect; Build Trust; and Hardwire Excellence. These principles lead us to our TRUE NORTH and inspire us to provide exceptional care. 

These values serve as the foundation of everything we do, guiding us to deliver individualized care with integrity and accountability. We are committed to fostering a culture of collaboration, where every team member is valued and empowered to contribute their best to the health and well-being of those we serve. 

This is an exciting time to join NorthBay Health.

As an independent, nonprofit health system north of the San Francisco Bay Area, in the Napa/Solano Region, we are expanding our footprint across Solano, Yolo, and Napa counties to meet the evolving needs of our communities. With two acute-care hospitals—including a Level II Trauma Center and a modern maternity unit with a Level III Neonatal Intensive Care Unit (NICU)—along with a comprehensive cancer center, multiple urgent care facilities, and a growing network of primary and specialty clinics, we are investing in the future of care across the region.

NorthBay Health we are home to advanced clinical programs and nationally recognized cardiovascular, neuroscience, and orthopedic services, as well as comprehensive surgical and outpatient specialties. Our commitment to excellence is reflected in our Magnet with Distinction designation for nursing (one of only 12 organizations nationwide) and recognition from U.S. News & World Report as “High Performing” in multiple clinical areas, including maternity care, heart failure, and stroke. NorthBay Medical Center has earned the High Performing designation in maternity care for four consecutive years.

As the only locally governed health system in the region, we remain deeply rooted in our communities while growing into a trusted regional healthcare leader. If you are seeking meaningful work, collaborative teams, and the opportunity to help shape the future of healthcare in Northern California, you will find it at NorthBay Health.

Join us with our commitment to excellence, to achieve our vision to be the trusted healthcare partner of choice for the communities we serve.

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