Population Health Manager

Greater Baden Medical Services, Inc.•Brandywine, MD

3h•$90,000 - $100,000

About The Position

The Population Health Manager leads population health initiatives, oversees clinical and community outreach strategies, and monitors Managed Care Organization (MCO) engagement with GBMS. Using CRISP data and quality metrics, this manager directs disease management programs, monitors socioeconomic drivers of health, including redeterminations, and manages the Population Health Team to improve health outcomes and reduce health disparities. The role supervises the team’s daily workflows; uses CRISP health information exchange tools to support care coordination, Maryland AHEAD Model objectives, timely follow-up appointments, and patient education; and oversees HEDIS, Value-Based Care, gaps-in-care, and no-encounter reporting. The manager participates in PCMH frameworks, emergency department diversion, and quality improvement initiatives; administers member incentive programs; manages disease-management workflows and high-risk care coordination; and develops health education and promotion programs. The position coordinates transitions of care with clinic and hospital staff, serves as the primary MCO liaison, plans community engagement and health-literacy events with MCOs and community partners, and assesses social determinants of health to identify access barriers and reduce disparities. Additional duties include supporting special clinical initiatives and grant programs, training staff on preventative care education, and completing other assigned projects. The position operates in a professional office environment and requires travel between Greater Baden Medical Services locations. It routinely uses standard office equipment. Physical and mental demands include remaining stationary for 50% of the time, frequent computer and office-machinery use and communication, managing changing tasks and interruptions, adjusting priorities, coping with stress, and analyzing information from multiple sources.

Requirements

Bachelor of Science in Nursing (BSN), or a bachelor’s degree in Public Health, Health Administration, or a closely related field.
At least 3 years of experience in population health, care coordination, public health, or outpatient clinic settings.
At least 1 year of supervisory or team-lead experience managing clinical or community outreach staff.
An active RN license is required for applicants applying with a BSN.
Ability to read and interpret written or verbal documents and instructions, and speak effectively with patients, employees, and organizational stakeholders.
Ability to communicate accurately, summarize and exchange information, and maintain accurate records and data.
Ability to cope with stress, manage interruptions and changing tasks, and adjust priorities as circumstances dictate.
Ability to remain stationary for 50% of the time and routinely operate a computer and other office productivity machinery.
Ability to analyze, count, summarize, and synthesize information from multiple sources.
Ability to drive between Greater Baden Medical Services locations.

Nice To Haves

Hands-on proficiency with CRISP (Maryland Health Information Exchange) tools and dashboards.
Working knowledge of HEDIS, Value-Based Care (VBP), and EHR platforms.

Responsibilities

Directly supervise, mentor, and manage the daily workflows of the Population Health Team.
Use CRISP health information exchange platforms, including inpatient and emergency department notifications, discharge alerts, panel processors, and multi-payer reporting, to support care coordination, Maryland AHEAD Model objectives, timely follow-up appointments, and patient education.
Provide ongoing staff training and guidance on member health education, preventative care navigation, and health literacy strategies.
Oversee statistical data and reporting related to HEDIS, Value-Based Care, gaps in care, and no-encounter reports to guide outreach and program improvements.
Participate in PCMH frameworks, emergency department diversion projects, and quality improvement initiatives aimed at appropriate utilization and fewer hospital readmissions.
Monitor and administer member incentive programs encouraging annual preventative visits and HEDIS compliance.
Manage disease-management workflows for patients with comorbidities and oversee high-risk care coordination with the clinical team.
Develop, implement, and evaluate health education and promotion programs, including Diabetes, Asthma, Prenatal/Postpartum, and Dental Health programs.
Coordinate with clinic and hospital staff to ensure patients discharged from emergency departments, urgent care centers, or inpatient stays receive follow-up appointments and telephonic instruction.
Serve as the primary liaison with MCOs, align initiatives, track MCO engagement, and advance the agency’s mission.
Draft and oversee schedules for community engagement, health-literacy events, and outreach with MCOs and local community partners.
Assess socioeconomic factors and social determinants of health to identify and eliminate access barriers and reduce health disparities.
Support special clinical initiatives, designated screening or clinic days, and activities required by assigned grants and special programs.
Train staff on educating members about the importance of preventative visits.
Complete other projects and duties assigned by the supervisor.
Drive between Greater Baden Medical Services locations.
Comply with the Health Center’s Standards of Conduct, Compliance Program, and policies and procedures.