St. John's Episcopal Hospital is recruiting for a High Utilizer Population Health Manager. This position plays a central role in the organization readmission reduction strategy, focused on the inpatient high utilizer patient poplulation as well as the ED High utilizer patient population. This Manager is responsible for identifying all inpatients meeting HU definition, ensuring a Driver of Utilization (DOU) assessment on 100% HU admitted to the hospital, and assessing the treatment team with whole person transitional care planning and ensuring effective community linkages. Visits to patient homes and social services/community agencies are required of the position. This position will also provide Supervision of the ED Patient Navigator(s) Community Health Workers/Interns, and PAM Mental Health Coaches within the Population Health Department.
We offer 403B, Excellent PTO, Competive Salary, and tuition reimbursement
Responsibilities Include, but not limited to:
Daily access of HU inpatient report and distribution of Bedboard Committee and HU Action Squad
Provide administrative support to MAX Action Team and support for all ongoing HU admission reduction strategies.
Develop and populate data reegistry of HU patients and create all necessary reports
Meet regularly with interdisciplinary team to reiew patients action plans, modify workflows, as required, and ensure closure of loop
Assist Action team in analyzing the effectiveness of implemented strategies
Attend all MAXny Series Action team meetings, including phone calls, on-site workshops, webinars, internal meetings, and calls/meetings with communityh partners
Works closely with social worker, palliative care team, care manager, unit nurse, medical team, pharmacist, and MD champion to mitigate DOU
Skills/Requirements
Bachelor's Degree required, preferable in Social Services or Public Health field.
Bilingual (Spanish speaking) preferred.
Experience working in a community based setting/social services agency for at least 2 years preferred (including case management, outreach,social service support, client education, focused on underserved, multicultural, and high risk patient populations.
2 years of Management experience preferred
Knowledge of medical terminology preferred
Excellent Microsoft Office, with ability to create and manage data registries and perform basic analysis.
Good communication skills
Ability to willingness to provide emotional support, encouragement and motivation to patients/families/caregivers.
