Population Health Medical Director

Reporting to the CEO, the Population Health Medical Director will be the primary owner of physician engagement strategies and tactics. They will be responsible for developing, deploying, and championing a transformational clinical strategy for improving population health outcomes, quality and experience of care, and cost of care for the populations served by DVACO in an environment which is rapidly moving towards significant downside financial risk. This position supports population health and clinical aspects of payer relations and contracting, provides clinical oversight of all care management and care transformation initiatives. Education: M.D. or D.O., Board Certification in Internal Medicine or Family Medicine (preferred) • Master’s Degree in Business Administration, Health Administration, Public Health or related field or equivalent related experience. Licensures & Certifications: Unrestricted PA medical license required, up to 20% FTE of ongoing clinical practice desirable Experience: At least 5 years of experience in leadership-level position with a proven track record in population health, with a strong preference for managing outcomes in a complex risk-bearing entity including a variety of populations (e.g. Medicare, commercial, employer-based) Direct experience with the Medicare Shared Savings Program (or equivalent) is strongly preferred. Experience with care models that support bundled/episode payments is a plus. Demonstrated ability to lead groups of physicians through change, with and without direct authority, using influence, trust, and thought leadership. Strong clinical background with at least 5 years in direct clinical practice, preferably in primary care. Experience in targeting programs at population health segments (e.g. chronic/complex illness versus health promotion) and measurement of program effectiveness. Proven strong leadership, business, communication, organizational, analytical and relationship skills. Proven experience in successfully facilitating...

Lead Outreach Coordinator

Lead Outreach Coordinator works under the supervision of the Director of Quality and in collaboration with other members of the DVACO outreach and health care teams. Identifies patient care needs for/with the health care team (providers and clinical support staff) and assists with care gap activities including protocol-driven care management services, practice transformation, and education for DVACO patients. Collaborates with patients, families, primary and specialty care providers in multiple practice sites to assist with care gap identification and closure, facilitate clinical guideline adherence, and coordinate services specifically related to the patients’ health care needs. Follows and assists with development of algorithms for assessed patient needs/gap closure, education pathways, clinical guidelines and diagnostic tests to aid the patient and primary care team with individualized plans of care. Maintains documentation and collaborates with the health care team to adjust interventions to maximize clinical, quality, and fiscal outcomes. Leads and/or participates in the integration of Quality Improvement and practice transformation activities/projects as required. Assists with development of Outreach team activities Oversees daily activities of Outreach team Education: Associates Degree in Health Care or graduate of an accredited clinically oriented program required. In lieu of degree, certified MA with at least 6 years of significant experience in a clinical setting will be considered. Licensures & Certifications: Current clinical certification/licensure (MA, LPN, RN) Experience: Minimum of three years of clinical experience required, preferably in an ambulatory setting. Previous management experience, Office Manager Experience preferred. We offer competitive compensation and outstanding comprehensive benefits including tuition reimbursement, 403B matching savings plan and a pension plan. If interested, please apply online at https://www.mainlinehealth.org/careers , Job ID 45726...

Health Coach

The Health Coach will support clients with achieving health improvement goals, reducing lifestyle related risk factors, and effectively managing any health conditions. They will be responsible for developing a strong rapport with each client using motivational interviewing techniques, and a participant centered approach. Coaches will use a holistic approach to consider all aspects of health behaviors, which could impact the success of the client. Coaches must be passionate about helping others achieve optimal health and wellbeing. They should be knowledgeable, professional, personable, and be able to connect with and inspire a wide variety of client personalities and temperaments. This is a part time 20-hour a week position, 4-8pm or 5-9pm 5 days a week. Weekend coverage needed, one Saturday morning occasionally. Position will initially work from home but must be able to travel to Radnor and other local DVACO facilities as needed. Education and Training: Minimum of a Bachelor’s Degree in Nursing, Health Education, Exercise Science, Nutrition, or other health related field. Certification in Health / Wellness Coaching preferred Experience and Knowledge: Three years of experience in health coaching, nutritional counseling, nursing, health education or similar role. Broad knowledge of the causes of chronic illnesses such as heart disease, diabetes, hypertension, obesity/metabolic syndrome, etc. Experience in applying lifestyle factors and behavior change to accomplish disease prevention and risk reduction. Expertise in behavior change concepts and theories including motivational interviewing, readiness to changes, health belief model, etc. Licensure and/or Certification: Certifications in Coaching, Dietetics, Health Education, Counseling, etc. preferred. Skills: Adept at motivating clients to take action to improve their health habits, including exercise, healthy eating habits, weight management, tobacco...

Care Coordination, Clinical Analyst

JOB SUMMARY: The DVACO Clinical Care Analyst assigned to Care Coordination will work directly with the Manager of Care Coordination to positively influence the quality outcomes and reporting metrics in the Care Coordination environments of care. The essential accountabilities of the job description will be applied to the Care Coordination environment working specifically but not exclusively with our Care Coordination staff and our Pod partners to manage patient referrals and report out on care coordination activities. The Care Coordination Clinical Care Analyst will work with Wellcentive, Patient PING platform, Formsite, Microsoft Excel and Access and other similar tools yet to be defined to meet the essential accountabilities. Healthcare knowledge and prior experience working in the hospital or physician practice is preferred. Works as part of the DVACO Clinical team to collect, process, integrate, analyze and present data; provide tools, descriptions, answers and guidance for projects to improve clinical quality and financial success for the ACO and its participating partners. Manages and meets reporting deadlines for assigned deliverables and ad hoc reports. Role will provide administrative, project management and care coordination/transitions of care support to the team. ESSENTIAL ACCOUNTABILITIES: Administrative duties. Managing relationships includes electronic, phone, and in person communication often with direct consultation with clinical staff to help manage the DVACO patient population. Arranges subcommittee meetings (schedules, produces documents, and compiles meeting notes) to support the DVACO clinical initiatives. Serves as technical support to clinical staff in trouble shooting issues with care coordination and information management software. Collects data from disparate partners and from various sources including the care coordination software, to produce daily, weekly and monthly reports to...

Care Coordinator RN

JOB SUMMARY: The RN Care Coordinator (Health Coach) is a Registered Nurse who facilitates patient continuity of care with the healthcare team. Under the clinical direction and oversight of the Primary Care Physician, the Care Coordinator coordinates care for high risk/complex patients by collaborating with the patient, family, physician, nurses, and other members of the healthcare team to identify needs and expedite appropriate, cost effective care. S/he assists in the development of the patient’s care plan and collaborates with the Primary Care Physician to provide leadership in issues of outcomes management, disease management and prevention, and development of improved strategies to benefit high risk patients. The Care Coordinator will serve as the patient’s primary conduit to the primary care provider as they help coordinate necessary services both within and outside the practice, coordinating care from a variety of sources—physicians, specialists, home care providers, rehab centers, pharmacists, etc. They will engage patients and encourage them to take an active role in their health by providing them with the tools necessary to make healthy lifestyle choices and adopt life-long healthy behaviors. ESSENTIAL ACCOUNTABILITIES: Contact ACO members to determine if there is a need for case management intervention based on guidelines, protocols and timeframes established for the applicable clinical program. Provide care coordination according to program descriptions including member education, follow up on a timely basis and eliminating barriers to care. Conduct comprehensive assessments that include the medical, behavioral, pharmacy, and social needs of the member. Review data for services the member has received and identify gaps in care based on clinical standards of care. Based on assessment of members needs and...