Position Summary
The Population Health Resource is responsible for supporting organization-wide and regional population health initiatives. This role is responsible for driving measurable performance across value-based care program partnerships through advanced data analysis, dashboard developments, partner accountability frameworks, workflow development, and team accountability. This role translates complex data into actionable insights, ensuring partners are aligned, accountable, and continuously improving within value-based arrangements. The population health resource will collaborate with the Population Health Director, Managed Care Team, and ACO Director to coordinate and execute population health-based partnerships and outcomes.
Key Responsibilities
Value-based Program Execution
- Support performance across organization-wide risk contract partnerships including TEAM, ACO, JV partnerships, LEAD, and others.
- Monitor utilization, outcomes, and cost drivers to identify opportunities for improvement
- Collaborate with internal and external stakeholders to align care delivery with program goals
Risk-based Patient Coordination
- Implement care coordination workflows for High-Risk ACO patients, in collaboration with ACO Director
- Lead initiatives to improve hospital-to-home transitions for high-risk patient populations
- Identify and manage high-risk patients to reduce avoidable readmissions
- Partner with care teams to implement best practices in post-discharge care planning and follow-up
- Audit readmissions cases and drive targeted clinical and operational improvements
Partnership & Network Development
- Build and maintain strong relationships with hospitals, physician groups, SNFs, ALFs, and other referral sources
- Serve as a key liaison between post-acute providers and acute care partners
- Participate in collaborative meetings with contracted partners to review performance and align improvement strategies
Data Analytics & Reporting
- Analyze trends in readmissions, utilization, and patient outcomes to inform strategy
- Support development and use of reporting tools (dashboards, Power BI, care coordination reports, JOC reports)
- Translate data into actionable insights for clinical teams, leadership, and external partners
Business Development Support
- Partner with business development teams to grow referral networks
- Assist in development of presentations and data-driven materials for partner engagement
- Provide educational outreach to demonstrate value in population health-based relationships and contracts
Operational Excellence & Process Improvement
- Identify workflow inefficiencies across referral intake, care coordination, and transition processes
- Support implementation of new tools, technologies, and standardized processes
- Train and mentor staff across care coordination and intake functions
Qualifications
Education & Licensure
- LPN or RN required
- Health Information Technology education or certification strongly preferred
Experience
- 8+ years in healthcare, with strong experience in hospital, post-acute, or care coordination settings
- Direct experience working with value-based care models (ACO, BPCI-A, CJR strongly preferred)
- Experience managing relationships with hospitals and physician groups
- Background in care transitions, intake, or referral management highly desirable
Technical & Analytical Skills
- Experience with data tools such as Power BI, Tableau, or similar reporting platforms
- Familiarity with various digital platforms (EMRs, HCHB, Allscripts, Meditech, PCC, Careport, Curaspan, etc.)
- Experience with population health tools (Trella, SHP, Medalogix, etc.)
The employer for this position is stated in the job posting. The Pennant Group, Inc. is a holding company of independent operating subsidiaries that provide healthcare services through home health and hospice agencies and senior living communities located throughout the US. Each of these businesses is operated by a separate, independent operating subsidiary that has its own management, employees and assets. More information about The Pennant Group, Inc. is available at http://www.pennantgroup.com.