Director of Community Care Team (CCT)

Director of Community Care Team (CCT) job, Full-time, Population Health Management

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 24/7. 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, its medical staff, and the HEDIS lead to keep patients healthy by filling care gaps, ensuring support during transitions of care, including in the physician’s office as needed. The Director of CCT will assume 24/7 accountability with the CCT as needed to support the team and the patients needing care.

Job Duties and Responsibilities:

• Supervises Staff and scheduling of care coordination for CCT 24/7 coverage:
  • Coordinate and assist with clinical recruitment, orientation/training.
  • Conduct clinical performance appraisals.
  • Reviews schedules for effective clinical coordination 24/7
  • Assigns and provides guidance for Health Coaches
  • Supervises scheduling for patients and community interventions.
  • Ensures accuracy of patient coordination
  • Reviews schedules for productivity
  • Create and maintain schedules for clinicians.
  • Works with CCN 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.
  • Daily communication with the CCT Medical Director
  • Coordinate clinical team to recognize and resolve care gaps.
  • Execute daily huddles and weekly meetings ensuring patient care requirements are being met.
  • Provides oversight of clinical services and operations with CCT team 24/7
  • 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
  • Assists in developing standards (care pathways) to coordinate health professionals for effective patient management.
  • Communicates with CCN team and the CCT for patient progress.
  • Along with the Medical Director of the CCT, meets with Health Coaches for progress reports.
  • 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.

• 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 situa