Charles River Community Health

Director

• Lead Quality Improvement and Clinical Quality initiatives for the health center to improve patient care and outcomes and foster a culture of quality and safety for the organization.
• Take the lead in communicating, and evolving over time, our organization-wide definition of quality, including reporting on progress and making recommendations to improve performance of foundational measures (e.g. patient satisfaction).
• Guide and support specific screening, prevention, and treatment initiatives, including long-standing breast cancer screening and follow-up efforts, our partnership with Dana-Farber Cancer Institute, and our HIV grant.
• Partner with the Chief Clinical Officer, the Director of Project Management, and other stakeholders across the Health Center to support Practice Transformation work consistent with Bodenheimer and the Safety Net Medical Home Initiative, including ongoing work on empanelment, team-based care, and quality improvement.
• Collaborate with Providers and Provider Champions in monthly meeting planning and management.
• Lead improvements in data analytics processes to develop timely, actionable data. This encompasses both data for quality improvement as well as population health activities.
• Manage the data development life cycle and serve as the primary point person running quality and population health reports utilizing Azara DRVS and Epic EHR systems, and review results with clinical leadership and subject matter experts.
• Facilitate meetings with ACO and managed care contract stakeholders in collaboration with Senior Leadership, including leading the reporting, oversight, and continuous improvement of key quality measures prioritized by clinical leadership, payors, and regulators (e.g., childhood immunizations, hypertension control).
• Monitor and analyze Health Center performance on quality/ACO metrics on an ongoing basis and ensure appropriate communication with providers and clinical leadership.
• Ensure that any deficiencies are promptly addressed.
• Evaluate, design, and implement population health programs.
• Develop effective tools to measure performance, run reports to analyze related data, and make recommendations to clinical and/or senior leadership based on findings and towards improving the quality performance at the health center.
• Partner with Health Center/Practice Leadership to transform and improve primary care as the Health Center participates in more advanced value-based payment contracts and models.
• Facilitate risk coding activities for the Health Center, helping to improve code capture.
• Identify process improvement gaps and work with staff to recommend and facilitate changes.
• Monitor and identify best practices within the Health Center/Practice and work in conjunction with others to implement and share organization-wide best practices.
• Work with Health Center/Practice staff to test and refine workflows that support sustainable transformation, and guide practice as they expand interventions to additional patient populations.
• Review regularly Health Center/Practice performance KPIs in the Population Health platform and other reporting structures, and inform Health Center/Practice leadership on insights, data trends, and leading or lagging performance.
• Work closely with Leadership and Associate Director of Risk and Compliance to facilitate clinical data collection or entry for regulatory, accreditation and grant-making organizations such as HRSA and PCMH.
• Train, support, supervise, and evaluate the Population Health team to ensure effective performance and achievement of program goals.
• Perform other duties as assigned by Chief Operating Officer or designee.

Director of Quality and Population Health

Human Resources

• Partner with the Director of HR to develop, implement, and refine HR strategies, policies, and initiatives.
• Serve as a trusted advisor to managers and staff, promoting a culture of collaboration, engagement, and professional growth.
• Support Director of HR with employee relations matters, acting as a trusted advisor for problem resolution and maintaining a positive work environment, while remaining in compliance with legal regulations and internal processes.
• Provide guidance to managers on employee relations issues, performance concerns, conflict resolution, and progressive disciplinary action.
• Collaborate with department leaders to assess staffing needs, workforce trends, and retention opportunities.
• Collaborate with hiring managers across the health center to ensure strategic candidate screening, effective interviewing processes, and clear communication.
• Document key variables to enable future data driven hiring decisions and move CRCH to a hiring the right fit model.
• Support recruitment processes by coordinating onsite interviews and shadowing days with hiring managers, including preparing staff for participation in interviews and facilitating on day of interviews.
• Develop behavioral interview guides and tools, including customized forms with feedback and rating sections, to set managers up for hiring success.
• Work with hiring managers to design and implement role-specific interviewing, onboarding, training, and development tools and processes.
• Collaborate with leaders to identify training, development, and coaching needs across the organization.
• Assist in building career development pathways and departmental succession planning strategies.
• Provide regular coaching for select managers and targeted coaching for those in need of development, with timelines and metrics to track progress.
• Meet with internal candidates applying for management roles to assess their readiness, provide feedback, and ensure alignment with hiring manager expectations.
• Deliver individualized training for new and newly promoted hiring managers on hiring processes, performance management, payroll workflows, progressive discipline, ATS utilization, and other essential HR systems and processes.
• Work with HR Generalists to develop and deliver bi-monthly leadership training workshops and peer learning round tables, to support manager development of the essential skills for leadership success.
• Monitor and update job descriptions as needed, ensuring alignment with organizational goals, and provide guidance to recruiters when necessary.
• Guide the Internship Coordinator and relevant hiring managers to strategically and proactively plan for grant funding and additional staffing.
• Provide support to HR with design, execution, and evaluation of organization-wide culture and engagement initiatives to enhance staff satisfaction and retention.
• Perform additional duties as assigned by the Director of Employee Relations and Human Resources, Chief Operating Officer, or designee.

Associate Director, Human Resources

Compliance

• As the compliance expert for CRCH, provides education to CRCH leaders, staff and clinicians across all departments on the topics of compliance and risk management utilizing CRCH MedTrainer (an online educational tool) and other resources.
• Works with the Senior Leadership Team and managers to establish an annual risk and compliance training plan at the organizational and department level and ensures completion of all training.
• Carries out on-site compliance rounding along with periodic on-site shadowing of clinical services in all areas, as well as ongoing staff education and training to stay in compliance with evidence-based guidelines.
• Informs management of any incidents (and escalates significant incidents).
• Conducts investigations and root cause analysis to address individual risk incidents and recommend system changes to reduce risk going forward.
• Leads the organization in developing, updating and maintaining patient safety, risk and compliance, policies, procedures and objectives along with department subject matters, as needed.
• Ensures all policies are uploaded into the MedTrainer system.
• Must also keep an updated binder with all copies of current policies for any site visits.
• Leads and coordinates the validation of actual clinical and operations performance versus policy and procedures outlines.
• Assists departments to ensure the two are in alignment.
• Follows through on patient complaints and grievances to ensure they are resolved, as well as tracking them in the MedTrainer system.
• Reports on meaningful trends and insight to leadership.
• Responsible for staying current on Risk and Compliance regulations and making annual recommendations for updates to core training offerings for CRCH staff to take.
• Takes the lead in establishing and carrying out CRCH Annual Risk Management Training.
• Responsible for the ongoing CRCH wide accreditation status, directs self-assessment, site visit, and malpractice renewal process (FTCA application) as required by HRSA.
• On an annual basis, assesses, coordinates, and submits required HRSA items.
• Monitors action plans throughout the year for compliance.
• Takes the lead for the ongoing CRCH wide licensure and certification status, and directs the self-assessment, site visit and clinic licensures renewal process as required by the state Department of Public Health.
• Ensures compliance and maintenance of related certificates including CLIA for on-site laboratory services.
• Accountable for the ongoing CRCH Patient Centered Medical Home certification and is responsible for renewal.
• Works with clinical and operational leaders to ensure compliance and maintenance of related documentation.
• Works in concert with VP of Operations, Chief Clinical Officer, Nursing, Clinical and Operational management, when necessary, in gathering and documenting information pertaining to all potential liability claims and high-risk areas.
• Assists senior management/leadership and directors in the coordination of on-site investigations by various external reviewers (i.e., DPH, CMS, HRSA).
• Assists senior management and directors in the implementation and ongoing measurement of various CRCH initiatives relating to patient safety, patient satisfaction, risk and compliance, and safety standards.
• Stays up to date on regulatory and external policy changes impacting CRCH and recommends policy and procedure changes to leadership for implementation.
• Chairs the Patient Safety Committee with the clinical directors to discuss safety events and incident reports.
• Supports clinical leadership in identifying training needs and in developing and delivering training on both compliance and non-compliance subject matter.
• Responsible for the Risk and Compliance introduction during New Hire Orientation.
• Works with clinical leadership to develop clinical workflows and polices that ensures the health center is/stays compliant.
• Assists the IT department in running monthly Electronic Health Record Audits of employee access.
• Works with managers and supervisors to ensure all staff are maintaining and following HIPAA guidelines and preserving patient confidentiality.
• Assists in identifying high-risk or complex patients in Epic and flagging any patients who have a history of being disruptive.
• Perform other duties as assigned by Chief Operating Officer or designee.

Associate Director – Risk and Compliance

Manager

• Identify and recruit appropriate patients for care management from lists and referrals, in collaboration with primary care providers.
• Meet the patient where he/she is; observe the patient without intervention or judgment.
• Has knowledge of common chronic medical conditions presented in the population served and is able to:
• Educate the patient on their medication conditions and medications, and build their self-management skills;
• Use motivational interviewing to promote behavioral change.
• Assess, triage, and rapidly respond to clinical changes that could lead to the need for emergency services if not intervened upon.
• Conduct medication reconciliation in conjunction with the clinical pharmacist.
• Engage members and caregivers in active care planning with a focus on medical, behavioral, social, member-centered care needs.
• Coach and guide member/representative to meet bio/psycho/social goals.
• Provide care coordination, which may include but is not limited to facilitating care transitions, supporting the completion of referrals, and/or providing or confirming appropriate follow-up.
• Delegate assignments to Community Health Workers and/or Patient Navigators or Social Workers, follow up on completion, and be consistently available for timely consult regarding patient matters during business hours.
• Meet regularly with medical directors and nurse care managers, and speak as needed with Primary Care, ED, and inpatient to triage program issues appropriately when patients are discharged from hospitals.
• Participate in local site operations, including team meetings.
• Actively participate in planning and growth of the program as needed, to respond to evolving needs of Mass Health ACO.
• Maximize the use of ACO care management tools and technology to ensure that work is comprehensive, detailed, automated and streamlined to the extent possible.
• Make recommendations to change workflows to enhance the ease of use, practicality, and effectiveness of the ACO tools and processes.
• Understand the relationship between work done in the ACO's system and the work done in EHR.
• Ensure that workflows are optimized to recognize and support both the ACO's system and EHR.
• Facilitate interdisciplinary consultation on patient's behalf through participation in rounds, team meetings, and clinical reviews.
• Establish and comply with quality metrics for performance and adhere to documentation and work flow standards.
• Maintain HIPAA standards and confidentiality of protected health information.
• Adhere to departmental/organizational policies and procedures.
• Provide assistance in seasonal influenza/COVID vaccination efforts when applicable.
• Participate in the integrated care team meetings and rounds as required.
• Maintain accurate, timely documentation in electronic systems including health center EHRs.
• Provide coverage for team members who are out of office.
• Serve as the point person for enrollees coming out of the Transitions in Care Program and moving into CCM.
• Take all needed steps that this process is seamless for care team members and the enrollee, family, and caregivers.
• Ensure that all care management is offered in a culturally and linguistically-appropriate manner and with disability competence.
• Ensure that all necessary accommodations are consistently made for members with disabilities.
• Promote a sense of teamwork through demonstration of self-direction and self-motivation.
• Solve problems independently or know when to seek consultation.
• When onsite, co-locate near the medical nursing and provider teams for teambuilding.
• Perform other duties as assigned by the Lead Chronic Care Nurse or designee.

Chronic Care RN, Care Manager

• Identify and recruit appropriate patients for care management from lists and referrals, in collaboration with primary care providers.
• Meet the patient where he/she is; observe the patient without intervention or judgment.
• Has knowledge of common chronic medical conditions presented in the population served and is able to: Educate the patient on their medication conditions and medications, and build their self-management skills; Use motivational interviewing to promote behavioral change.
• Assess, triage, and rapidly respond to clinical changes that could lead to the need for emergency services if not intervened upon.
• Conduct medication reconciliation in conjunction with the clinical pharmacist.
• Engage members and caregivers in active care planning with a focus on medical, behavioral, social, member-centered care needs.
• Coach and guide member/representative to meet bio/psycho/social goals.
• Provide care coordination, which may include but is not limited to facilitating care transitions, supporting the completion of referrals, and/or providing or confirming appropriate follow-up.
• Delegate assignments to Community Health Workers and/or Patient Navigators or Social Workers, follow up on completion, and be consistently available for timely consult regarding patient matters during business hours.
• Meet regularly with medical directors and nurse care managers, and speak as needed with Primary Care, ED, and inpatient to triage program issues appropriately when patients are discharged from hospitals.
• Participate in local site operations, including team meetings.
• Actively participate in planning and growth of the program as needed, to respond to evolving needs of Mass Health ACO.
• Maximize the use of ACO care management tools and technology to ensure that work is comprehensive, detailed, automated and streamlined to the extent possible.
• Make recommendations to change workflows to enhance the ease of use, practicality, and effectiveness of the ACO tools and processes.
• Understand the relationship between work done in the ACO's system and the work done in EHR.
• Ensure that workflows are optimized to recognize and support both the ACO's system and EHR.
• Facilitate interdisciplinary consultation on patient's behalf through participation in rounds, team meetings, and clinical reviews.
• Establish and comply with quality metrics for performance and adhere to documentation and work flow standards.
• Maintain HIPAA standards and confidentiality of protected health information.
• Adhere to departmental/organizational policies and procedures.
• Provide assistance in seasonal influenza/COVID vaccination efforts when applicable.
• Participate in the integrated care team meetings and rounds as required.
• Maintain accurate, timely documentation in electronic systems including health center EHRs.
• Provide coverage for team members who are out of office.
• Serve as the point person for enrollees coming out of the Transitions in Care Program and moving into CCM.
• Take all needed steps that this process is seamless for care team members and the enrollee, family, and caregivers.
• Ensure that all care management is offered in a culturally and linguistically-appropriate manner and with disability competence.
• Ensure that all necessary accommodations are consistently made for members with disabilities.
• Promote a sense of teamwork through demonstration of self-direction and self-motivation.
• Solve problems independently or know when to seek consultation.
• When onsite, co-locate near the medical nursing and provider teams for teambuilding.
• Perform other duties as assigned by the Lead Chronic Care Nurse or designee.

Director of Quality and Population Health

Associate Director, Human Resources

Associate Director – Risk and Compliance

Chronic Care RN, Care Manager

Chronic Care RN – Care Manager