Senior Clinical Population Health Manager

Job Title: Senior Manager

Location: RWJ - 379 Campus Dr,

Somerset

Department Name: ACO

Req #: 0000238043

Status: Salaried

Shift: Day

Pay Range: $112,254.00 - $142,156.00 per year

Pay Transparency:

The above reflects the anticipated annual salary range for this position if hired to work in New Jersey.

The compensation offered to the candidate selected for the position will depend on several factors, including the candidate's educational background, skills and professional experience.

Job Overview:

The Sr. Clinical Population Health Manager will oversee three key teams: Ambulatory Care Management, Inpatient Care Management, and Post-Acute Care Management. These teams drive patient care outcomes across the continuum, from preventive care to discharge planning and post-acute transitions.

Qualifications:

Required:

• Requires a minimum of three (3) years' experience serving members with special needs
• Requires strong knowledge of the standards of practice for care managers
• Requires strong knowledge of managed care principles
• Requires strong organizational skills
• Requires strong oral and written communication skills
• Requires good PC skills and the ability to utilize Microsoft Office applications (Excel, Access, Word, etc.)
• Requires good problem solving and conflict resolution skills
• Requires a car with valid New Jersey State License and Insurance for certain positions

Certifications and Licenses Required:

• NJ RN License

Essential Functions:

Ambulatory Care Management

Functionality:

• Chronic care management, transitions of care and disease-specific programs.
• Preventive care and quality gap closure. (focus for 2025 to reimplement care management team in quality and prevention by working with Director, Population Health)
• Referral management/ appointment scheduling (in-person/virtual follow-ups, SDOH screening/interventions- CHW collaboration, multi-visit patients case rounds).
• BHealthy Navigation Program: Recently expanded to include appointment scheduling support.
  • BHealthy Care Navigation: This team assists employees and dependents who subscribe to the health plan in locating providers, scheduling appointments, and connecting with resources, including Premier and Inner Circle providers and services.
  • Employee health plan-specific programs, such as Diabetes Care Management.

Oversight:

• Manage a team of Supervisor, RN Care Managers, Episode Coordinators, Social Workers, Network Administrator, Post-Acute Coordinators, and BHealthy Navigators.
• Ensure quality outcomes by tracking process, outcome, and engagement metrics (e.g., Five9 surveys)
• Lead the development of workflows to optimize chronic care and collaborations with other departments
• Facilitate discharges to home or home with services, prioritizing high-performing SNF placements when necessary
• Provide disease-specific education and coordinate follow-up appointments
• Collaborate with inpatient discharge planning teams to evaluate palliative care, hospice or other care management needs/referrals
• Monitor patient transition workflows and optimize IDR (Interdisciplinary Rounds)
• Participate in readmission reduction reviews and strategy development with hospital stakeholders (attend UR/UM meetings at each local hospital site monthly)
• Manage a high-performing SNF Post-Acute Network and conduct quarterly Joint Operating Committees (JOCs)
• Address escalations from inpatient and case management teams related to underperforming SNFs.
  • Use Point Click Care dashboards and risk stratification to improve workflows.
  • Support Care Link sign-up for all facilities in the high-performing network.
  • Maintain clinical attributes for the Epic CCSC referral management module.
• Develop initiatives to reduce SNF length of stay, readmissions, and return-to-hospital rates.
• Ensure accountability and quality performance across SNF partners.

Collaboration and Cross-Functional Work

• Lead interdisciplinary collaborations with IT/Epic, CDI, Nursing, Pharmacy, Case Management, Medical Group, service line leads (e.g., orthopedics, cardiovascular), VNAHG, and Skilled Nursing Facilities to drive seamless care transitions and improved outcomes.
• Collaborations with Rutgers Population Health
  • Colorectal Cancer Screening
  • Newsletter

Strategic Oversight

• Develop and maintain dashboards for KPI tracking and performance monitoring. (Need further refinement in 2025)
• Ensure compliance with system goals, including lowering the HRRP readmission rate and enhancing preventive care metrics
• 2025 initiative- planning phase: Provide leadership in designing and implementing workflows for palliative care services, remote patient monitoring, Hello World/Cheers campaign
• Lead initiatives such as centralized heart failure e-check-ins and expanded appointment scheduling to improve patient outcomes.

Leadership and Development

• Conduct regular leadership rounds at clinical sites, engaging with staff to address challenges and foster team morale.
• Mentor and train staff to ensure professional growth and alignment with organizational goals.
• Maintain and update job descriptions, ensuring clear expectations and role alignment
• Conduct QA audits and monitored productivity dashboards to ensure accountability and high standards.

Other Duties:

Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities and activities may change at any time with or without notice.