Population Health Management (Phm) Program Manager

FLSA Status: Exempt

Department: Quality & Process Improvement

Reports To: Director, Quality & Process Improvement

GENERAL DESCRIPTION OF POSITION

The Population Health Management (PHM) Program Manager ensures that the PHM program strategies and associated initiatives are in compliance with regulatory requirements (e.g. NCQA PHM standards, Department of Health Care Services (DHCS) contract requirements, All Plan Letters, etc.). This role serves as a critical resource and subject matter expert in supporting, monitoring, managing, interpreting regulation, driving strategic projects, interventions, and initiatives for the organization's PHM program.

This is a highly collaborative role that partners with internal teams across the company, external partners, and healthcare providers to ensure our programs are achieving our goals. The role uses a variety of data sources to determine performance across key performance indicators (KPI), identify insights and opportunities for performance improvements, and share these outcomes with stakeholders to drive continuous improvement.

ESSENTIAL DUTIES AND RESPONSIBILITIES

To perform this job successfully, an individual must be able to perform each essential duty listed below satisfactorily.

• Ensure PHM initiatives meet all regulatory requirements for PHM.

• Plan, manage, and evaluate program initiatives to improve performance especially as it relates to key components of PHM (as compliant with all regulatory requirements).

• Collaborate and coordinate with various stakeholders to implement self-management population interventions and member-centric programs and services.

• Lead and conduct the annual preparation, review, and approval process of the NCQA PHM Program Descriptions, Population Assessments, Evaluation Reports, required regulatory reports and development of work plan activities.

• Responsible for gathering and submission of PHM data, KPI generation, and any PHM related regulatory submissions.

• Assists in the development of PHM policies and procedures regarding the PHM program, as directed.

• Provide comprehensive analysis of measures, barriers, and opportunities, and present results of improvement efforts and ongoing performance measures.

• Stays informed about industry best practices and identifies opportunities to integrate best practices into SCFHP's PHM strategies.

• Facilitates any regulatory requirement cross-departmental workgroups and represents PHM in other cross-departmental meetings/workgroups, lead and present material at internal and external meetings, assist in regulatory reporting development, and develop/maintain PHM Program-related documents.

• Disseminates program updates, performance data, evaluation findings and recommendations for continuous improvement on a regular basis.

• Monitor the referral process for members with chronic conditions and tracking of members to appropriate care levels.

• Collaborate with stakeholders and update risk stratification methodologies to identify members in need of intervention.

• Collaborates with Quality Improvement staff to support HEDIS and quality improvement initiatives.

• Perform other related duties as required or assigned.

REQUIREMENTS - Required (R) Desired (D)

The requirements listed below are representative of the knowledge, skill, and/or ability required or desired.

• Bachelor's Degree in Public Health, or a related field, or equivalent experience (R)
• Master's Degree in Public Health, Health Sciences, Nursing or related field. (D)
• Minimum three years of experience with quality improvement in health related setting, including performing root cause analysis, Plan Do Study Act methodology and monitoring/analyzing improvement, program development. (R)
• Knowledge of Medi-Cal, NCQA, DHCS principles and practices. (R)
• Proven ability to design and execute strategic plans for continuous improvement initiatives. (R)
• Project Management experience. (D)
• Medicare Advantage plan or ACOs experience. (D)
• Ability to consistently meet accuracy and timeline requirements to maintain regulatory compliance. (R)
• Experience leading cross-functional projects. (D)
• Maintenance of a valid California driver's license and acceptable driving record, in order to drive to and from offsite meetings or events; or ability to use other means of transportation to attend offsite meetings or events. (R)
• Ability to form positive, professional relationships with internal and external stakeholders. (R)
• Working knowledge of and the ability to efficiently operate all applicable computer software including computer applications, such as Outlook, Word and Excel. (R)
• Ability to use a keyboard with moderate speed and a high level of accuracy. (R)
• Proficient in adapting to changing situations, working independently and efficiently alternating focus between tasks to support the operations as dictated by business needs. (R)
• Excellent communication skills including the ability to express oneself clearly and concisely when providing service to SCFHP members, providers and external stakeholders over the telephone, in person or in writing. (R)
• Ability to think and work effectively under pressure and accurately prioritize and complete tasks within established timeframes. (R)
• Ability to assume responsibility and exercise good judgment when making decisions within the scope of the position. (R)
• Ability to maintain confidentiality. (R)
• Ability to comply with all SCFHP policies and procedures. (R)
• Ability to perform the job safely with respect to others, to property, and to individual safety. (R)

WORKING CONDITIONS

Generally, duties are primarily performed in an office environment while sitting or standing at a desk. Incumbents are subject to frequent contact with and interruptions by co-workers, supervisors, and plan members or providers in person, by telephone, and by work-related electronic communications.

PHYSICAL REQUIREMENTS

Incumbents must be able to perform the essential functions of this job, with or without reasonable accommodation:

• Mobility Requirements: regular bending at the waist, and reaching overhead, above the shoulders and horizontally, to retrieve and store files and supplies and sit or stand for extended periods of time; (R)
• Lifting Requirements: regularly lift and carry files, notebooks, and office supplies that may weigh up to 5 pounds; (R)
• Visual Requirements: ability to read information in printed materials and on a computer screen; perform close-up work; clarity of vision is required at 20 inches or less; (R)
• Dexterity Requirements: regular use of hands, wrists, and finger movements; ability to perform repetitive motion (keyboard); writing (note-taking); ability to operate a computer keyboard and other office equipment; (R)
• Hearing/Talking Requirements: ability to hear normal speech, hear and talk to exchange information in person and on telephone; (R)
• Reasoning Requirements: ability to think and work effectively under pressure; ability to effectively serve customers; decision making, maintain a concentrated level of attention to information communicated in person and by telephone throughout a typical workday. (R)

ENVIRONMENTAL CONDITIONS

General office conditions. May be exposed to moderate noise levels.