Director of Community Care Team (CCT)

Population Health Nashville, Tennessee

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Description

Nashville General Hospital is hiring for a Director of Community Care Team (CCT) for Population Health Management as a full time job in Nashville, Tennessee.

The primary function of the Director is to supervise and manage clinical operations of the Community Care Team (CCT) and provide clinical oversight with the assistance of the Medical Director of the CCT. This position provides an integral role as a member of the interdisciplinary team whose purpose is to improve the ability of patients designated as high-risk to maintain and improve their health and avoid preventable hospitalizations and re-hospitalization. The Director of CCT, with the assistance of the CCT members and Community Care Network (CCN), will ensure continuity and coordination of care across transitions, including hospital/community facility to home; will identify barriers and facilitate optimal care delivery, including addressing gaps, medical, pharmaceutical, and social needs; and will develop a comprehensive care plan to address those needs that include prevention, patient self-management, access to community resources and education about their chronic disease condition. The CCT will work with the community, hospital, and its medical staff to keep patients healthy by filling care gaps, ensuring support during transitions of care, including in the physician’s office as needed. Along with the Community Care Team members, the Director of the CCT will participate in the rotating on-call schedule for weekly phone coverage and weekend hospital coverage.
Job Duties and Responsibilities: 
  • Supervises Staff and scheduling of care coordination for CCT coverage: 
    • Conduct clinical performance appraisals
    • Reviews schedules for effective clinical coordination and productivity
    • Assigns and provides guidance for Health Coaches
    • Supervises scheduling for patients and community intervention
    • Ensures accuracy of patient coordination
    • Create and maintain schedules for clinicians
  • Works with Community Care Network (includes clinic leadership and case management) and CCT members to effectively coordinate community resources and to support the community by participating in community events to support the patients in the CCN and under care of the CCT                                    
  • CCT Patient Care Management and CCT Clinical Operations: 
    • Effectively communicates and engages with core members of healthcare team across the continuum of care
    • Execute daily huddles and weekly meetings ensuring patient care requirements are being met
    • Provides education and guidance with the medical director for medical management of chronic disease
    • Works with Sr. Director of Population Health and the CCT Medical Director to establish patient selection criteria for High-Risk patients and care pathways
    • Acts as liaison with medical staff for appropriate patient selection
    • Communicates with CCN team and the CCT for patient progress
    • Leads Health Coach education program and core curriculum completion with assistance of CCT and Medical Director at participating schools
    • Engages volunteer services to support and train volunteers to become health coaches in the community
    • Works with Congregational Health and Education Network (CHEN) in running CHEN church clinics (includes staffing, resources needed, etc.)
  • Participates and leads, with the assistance of the Medical Director of the CCT, the Interdisciplinary Leadership (IDL) Care Committee: 
    • Leads discussion and intervene with various MDs in departments/facilities to enhance protocols, handoffs, transitions, and outcomes for patients
    • Holds staff accountable in fixing operational barriers and escalated unresolved situations to the CEO
    • Supports IDL and CCT in developing appropriate integrative Care Pathways, Protocols, Quality Metrics, Tracking and Auditing tools
    • Leads and develops interdisciplinary meetings with high utilizing insurance companies to intervene for high-risk patients and ensure care gaps are being addressed
    • Leads new initiatives to support patient care across the continuum in a no discharge process that includes care gap completion
  • Effectively communicates with core members of healthcare network to ensure an effective continuum of care: 
    • Provides clinical interventions/recommendations to team in daily huddles with difficult case presentations
    • Assists the CCT and IDL team in coordinating clinical team to recognize and resolve care gaps
    • Present CCT program and outcomes to Leadership and Board as requested
    • Supports the Medical Director in providing Physician Leadership and Education on the CCT, care gaps, population health management and community strategies for Nashville General Hospital
  • Quality Assurance Oversight 
    • Responsible for acquiring knowledge of accountable care act requirements to maintain compliance and improve value-based proposals and pay for performance measures
    • Ensures Consenting process is approved and completed for CCT patients
    • Works with Marketing on MD education programs and community education and marketing
    • Reviews audit checks with the CCT Medical Director for appropriate and compliant charting requirements from physicians
    • Reviews staff documentation for compliance of documentation
    • Works with IT and data staff ensuring baseline metrics and targets are developed and measured, reported out monthly to Hospital Leadership
 
Required Skills and Qualifications:
  • Minimum five years in healthcare management or clinical care.
  • Master's in Nursing or a Masters in a Health-related field, preferred. Bachelor's Degree required.
  • Experience with Care management plans preferred

About Nashville General Hospital

Nashville General Hospital (NGH) is Nashville’s original community- based hospital. Joint Commission accredited, NGH readily accommodates a wide range of needs from emergency services and acute care to ancillary and ambulatory services. NGH continues to maintain its strong commitment to the healthcare needs of Nashville and Davidson County underserved, while also providing care to all segments of the community.

Our benefits include:

  • Benefits begin on the first day of month after one full calendar month of employment
  • Programs to reduce share of deductible and total out-of-pocket expenses
  • Metro Health Incentive Program - Access to high quality healthcare without incurring out-of-pocket expenses
  • Short and Long-Term Disability - up to 60% of eligible weekly pay
  • Life Insurance - Metro provides you with basic life and AD&D coverage equal to $50,000 ($32,500 if you are age 65 or older), at no cost to you.
  • Retirement Plan - eligible up to IRS max limits and includes company contribution
  • Shift and Weekend Differential Pay Offered on Nights and Weekends
  • Tuition Reimbursement for employee and dependents
  • 12 paid holidays - any holiday worked is another holiday banked
  • Flexible Spending Accounts
  • Free Parking for all employees
Nashville General Hospital is an Equal Opportunity Employer/Disability/Veteran. 

We are an E-Verify employer.

For more information, please click on the following links:
E-Verify Participation Poster: English | Spanish
E-Verify Right to Work Poster: English | Spanish

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