Population Health Clinical Team Lead

St. Joseph's Health•Paterson, NJ

8h•Onsite

About The Position

Through ongoing review & analysis of cases, data, and workflows, the Population Health Clinical Team Lead works collaboratively with the Manager and Director of Population Health to develop care coordination programs with defined populations to ensure safe and effective transitions of care, reduce IP/ED utilization, and reduce re-admissions. As a clinical lead and point of contact for physicians, patients, families, caregivers, and nurse navigators, the Lead ensures that care plans are medically sound, cost-effective, aligned with clinical guidelines, and fulfilling quality measures. Additionally, the Lead serves as a resource for both patients and navigators, assisting in accessing clinical, supportive, and financial services within the St. Joseph Healthcare System and the community. The Lead supports care coordination efforts with SNFs (skilled nursing facilities) and various visiting home health agencies, as required. The Lead actively contributes to the integration and optimization of population health documentation to streamline communication, care coordination, and data flow.

Requirements

Clinical lead and point of contact for physicians, patients, families, caregivers, and nurse navigators.

Responsibilities

Develop care coordination programs with defined populations to ensure safe and effective transitions of care, reduce IP/ED utilization, and reduce re-admissions.
Ensure care plans are medically sound, cost-effective, aligned with clinical guidelines, and fulfilling quality measures.
Serve as a resource for patients and navigators, assisting in accessing clinical, supportive, and financial services within the St. Joseph Healthcare System and the community.
Support care coordination efforts with SNFs and various visiting home health agencies.
Actively contribute to the integration and optimization of population health documentation to streamline communication, care coordination, and data flow.