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...

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...