Team Lead - Value Based Care

SUMMARY

The Team Lead, Value Based Care is responsible for managing a team of VBC Specialists who will provide education, counseling, advocacy, and coordination of services to patients belonging to customers using the eClinicalWorks & healow product suite. The Team Lead and VBC Specialists will act as extensions of the patients Care Giver or Primary Care Provider (PCP) in helping to close the gaps in patients care. This individual will teach & supervise the team of VBC Specialists to build rapport with patients through one or two virtual sessions each month supporting them through services such as Chronic Care Management (CCM), Behavioral Health Integration (BHI), Principal Care Management (PCM) and Remote Patient Monitoring (RPM). Furthermore, the Team Lead will empower their team to help patients meet goals/ healthcare needs by utilizing active listening skills, investigating patient concerns, documenting appropriately, and communicating professionally with the patients care circle. The Team Lead and VBC Specialists will collaborate directly with multiple primary care office-based health care teams to provide patient-centered care and frequent follow-up with Patients and Providers. The Team Lead will also be responsible for establishing and enforcing key performance indicators (KPIs) and long-term / short-term goals for their team members in addition to working with leadership on future growth opportunities.

RESPONSIBILITIES

• Serves as the program leader for patient self-management and value-based care support programs.
• Provides education, coordination and support to the VBC specialists team on the follow-up and management of chronically ill patients.
• Provides monthly, quarterly and annual reporting as required for eClinicalWorks and for program certification.
• Reviews and revises processes & key performance indicators (KPIs) based on customer feedback.
• Adheres to and ensures compliance with CMS and other standards on patient follow-up for the various value-based care initiatives.
• Provides guidance and education to the VBC specialists team on program as well as process changes.
• Works with the VBC Specialist team, primary care providers, care center staff, and nurse managers to:
  • Ensure optimal collaboration with patients and families as well as high-quality patient assessments.
  • Utilize motivational interviewing techniques to assist patients with establishing self-management goals and action plans with timeframes.
  • Ensure timely implementation of assessments, care plans and appropriate interventions for identified patient populations to determine health, social situation, physical environment, mental health, substance abuse, economic status and educational needs of patients.
  • Foster an interdisciplinary team approach to address opportunities to plan and coordinate care for patients.
  • Leverage the eClinicalWorks and healow platforms to identify chronically ill patients and ensure continuity of care.
  • Foster the identification and utilization of cultural and community resources and maintains an accurate database of services and contact information.
  • Help to arrange contact with other resources needed to support patient treatment plans.
  • Develop and revise evidence-based educational offerings and care plans for chronic diseases such as diabetes, obesity, hypertension, and COPD.

The ideal candidate must be able to:

• Understand and stay current with the various value-based care and population health management programs (such as CCM, RPM, APCM, BHI, PCMH, etc.) prevalent in the healthcare industry.
• Oversee the management and support of patients' healthcare needs via telephone, tele visit, email and text conversations by the CCM Specialist team.
• Ensure that daily productivity goals and quality metrics are met within established standards.
• Oversee complete individualized patient care plans and perform care management and care coordination services via the eClinicalWorks & healow software platforms.
• Ensure that the VBC Specialists maintain contact with patients 1 or 2 times each month to provide care coordination, support, and manage compliance with the care management programs to increase positive outcomes.
• Ensure that there is optimal documentation of all communications with patients, their caregivers, and their providers accurately.
• Ensure timely communication to and from primary care teams regarding patient needs and/or life-threatening episodes and ensure comprehensive care plans are complete and accurate.
• Ensure adherence to documentation protocols and best practices for daily workflow, escalation of client issues, comprehensive care plans, and internal communications.
• Foster excellent customer service skills demonstrated by positive feedback from customers and patients.
• Speak to the benefit and value of Chronic Care Management, Remote Patient Monitoring and other similar programs, to ensure patient enrollment and retention goals are met.
• Ensure that the team complies with any internal audit requirements.

QUALIFICATIONS

• An RN degree with at least 2 years' work experience in your role.
• Proven team leadership abilities
• Familiarity with Chronic Care Management, Remote Patient Monitoring or similar value-based care programs.
• 1 - 2 years of experience and proficiency working with Electronic Health Records (EHR) software as a user
• Knowledge of healthcare terms, conditions, roles, and basic care principles

PREFERRED QUALIFICATIONS

• Attention to detail and thoroughness with a focus on ensuring compliance with healthcare rules & regulations.
• A quiet, uninterrupted dedicated workspace ensuring HIPAA compliance is met as well as reliable high-speed internet
• An ability to teach the development and building of trusting relationships with patients and partner practices
• Demonstration for a passion for caring for patients and guiding them in their health journeys
• Ability to stay flexible and quickly adapt to new processes, software changes, and priorities
• Ability to pass a background check
• Willingness to learn new skills on a continuous basis
• A positive attitude
• Empathetic and active listener with the ability to thrive independently in a fast-paced environment