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The National Director, Care Integration Strategy & Program will be responsible for the end-to-end program effectiveness to build and establish operational and strategic goals and objectives consistent with PCO Strategic Initiatives. Will lead and oversee the strategic planning, development, and execution of initiatives aimed at optimizing patient care transitions across the primary care continuum. The incumbent will play a pivotal role in reducing acute care utilization for top 5% of complex patients and ensuring seamless transitions of care for patients within the Primary Care Organization (PCO), hospital systems, and other patient care facilities that ultimately improve care standardization and resource utilization, reduce readmissions and enhance/optimize patient outcomes, satisfaction, and operational efficiency.

Coordinate quality improvement activities to address high risk, high-utilizers/high-cost patient management through the utilization of the 5M’s framework as well as transitions of care, best practices to guide policy and procedure development derived from the best evidence practices.

Provide ongoing program support through active communication, education, and consultation with clinical staff and leaders. Responsible for communicating with key stakeholders across the organization while creating communications and coordinating statistics and analysis of data to track and trend for the purpose of improving programmatic and performance on issues related to reducing acute care utilization, safe transitions, readmission reduction, and other clinical programs as determined.

The National Director, Care Integration Strategy & Program is a critical leadership role responsible for the success of the portfolio of Care Integration programs  within the Complex Care vertical of centralized programming to serve CenterWell Senior Primary Care’s (and Conviva Senior Primary Care’s) highest need and complexity patients with care and case management services. The Director is response for the strategic direction, execution and ongoing management of our High Risk Patient Management (HRPM) program, Transitions of Care Management (TCM) program, and Episodic Consult (single-use case specific offerings) programs designed to improve quality and reduce costs for high-risk senior populations in full-risk Medicare arrangements. The Director will lead and oversee the strategic planning, development, and execution of initiatives aimed at optimizing patient care transitions across the primary care continuum.

This leader will play a pivotal role in reducing acute care utilization for the top 5% of complex patients and ensuring seamless transitions of care for patients within the Primary Care Organization (PCO), hospital systems, and other patient care facilities that ultimately improve care standardization and resource utilization, reduce readmissions and enhance/optimize patient outcomes, satisfaction, and operational efficiency. The leader will be responsible for ensuring programs coordinate quality improvement activities to address high risk, high-utilizers/high-cost patient management via the 5M’s framework as well as transitions of care and other guideline, workflow and procedure development derived from the evidence-based practices.

Working in a highly matrixed environment, the Director will collaborate closely with clinical, operations, analytics, medical economics, technology, and finance teams to optimize program delivery and drive measurable outcomes. The ideal candidate will possess a strong strategic and program operator background (particularly with a lens toward VBC provider delivery offerings), a deep understanding of value-based care principles, and a proven ability to lead and motivate cross-functional teams. This leader will provide ongoing program support through active communication, education, and consultation with clinical and operational leaders, and is responsible for engaging with key stakeholders across the organization while creating communications and coordinating data analysis and insights to track and trend for the purpose of improving programmatic performance on issues related to reducing acute care utilization, safe transitions, readmission reduction, and other clinical programs as determined.

Portfolio scope

• High Risk Patient Management Program – Care and case management interdisciplinary offering for top 5% highest need patients

• Transitions of Care Management Program – Post acute care management interdisciplinary offering for patients following an acute IP/Obs utilization event

• Episodic Consults Program – Unique need (i.e., single resource) offerings for bridging or episodic support for medication management, chronic disease management, deprescribing, beha