Director, Disease Management
Reporting to the Chief Medical Officer of SHS and the Chief Medical Officer of Sinai Medical Group, this position Provides Leadership and Direction to the SHS Disease management Program, a central function for Sinai’s Population Health Initiatives.
- Directs/leads the SHS Disease Management Program; develops inpatient and ambulatory disease management programs across the continuum of care; Monitors the effectiveness of the program and recommends changes to structure and processes as needed.
- Provides direct supervision to the interdisciplinary team of nurse disease managers, pharmacists, social workers, dieticians, and community health patient navigators who are responsible for the coordination of care; Evaluates quality and effectiveness of work product through regular reviews and ongoing feedback.
- Designs and implements effective care coordination processes that include a comprehensive assessment of patients and their self-management abilities;, procedures for effective health coaching including teachback methods, identification of patient resources that are comprehensive and culturally appropriate; and engagement with physicians, patients and their families. Oversees the training and implementation of these processes within the Disease Management Program.
- Working with the interdisciplinary team, develops and implements disease specific protocols and order sets for the entire continuum of care based upon the latest evidence based recommendations; Collects data on the utilization and effectiveness of these tools and recommends changes as necessary and as the evidence changes.
- Develops effective working relationships with PCPs, Specialists, care team members, home health agencies, SHS administrative leadership, medical leaders, SCI and SUHI program staff, clinic networks, and other support organizations.
- Creates standards and methods for disease management documentation in the EMRs; Assures that an appropriate disease management plan of care is created and documented for the patient that is based upon the physician’s plan of care.
- Serves as the primary contact for Sinai initiatives involving external grants, demonstration projects such as Bundled Payment, High Value Healthcare Collaborative; Represents the Disease Management Program on internal projects.
- Working collaboratively with the applicable CMOs and Manager of Ambulatory Quality, plans the activities of the SMG Clinical Integration Committee; Provides support and reports on the various strategies and outcomes that are related to the Disease Management Program.
- Maintains current working knowledge of the myriad of strategies to improve population health; Identifies and evaluates new technologies to improve patient engagement and the provision of disease management services including health coaching
- Manages grant activities including report preparation and budgets. Seeks out new opportunities for funding.
- Creates and maintain all Disease Management operations policies and procedures. Provides training and education to all staff members.
- Participates in the review of managed care contracts as they pertain to the provision of care coordination services; Maintains relationships with contracted entities and other external organizations to minimize duplication of initiatives which may impact patient experience.
- Develops and completes presentations to the SHS caregivers, medical staff, residents on the Disease management initiatives to promote their understanding of these activities and to promote referral of appropriate patients.
- Performs other duties as assigned.
- Bachelor’s Degree in Nursing field or other healthcare degree; Master’s Degree strongly preferred.
MINIMUM WORK EXPERIENCE:
- Minimum five 5-8 years experience in a related clinical position strongly preferred; 2-4 years of supervisory experience required; Prior experience in disease management/care management/health coaching required.
KNOWLEDGE & SKILLS:
- Demonstrated leadership/supervisory skills
- Demonstrated program development experience especially as it relates to the improvement of population health and disease management
- Demonstrated knowledge and experience in management of disease processes
- Experience working on national projects related to the disease management field
- Experience developing disease registries desire
- Excellent oral, written, and interpersonal communication skills. Ability to work independently and also as a team with a wide variety of individuals; Excellent organizational skills
- High degree of creativity in problem-solving; ability and patience to navigate and impact complex systems of care.
- Proficient computer skills