Population Health Case Manager & Liaison

Description

The Population Health Case Manager and Liaison plays a critical role in coordinating patient-centered care and health initiatives across populations, while serving as the primary point of communication between the internal healthcare organization and external, outsourced partners. This role ensures that care management programs are executed efficiently, patient outcomes are improved, and partnership operations are aligned with the organization’s goals and compliance standards.

Requirements

Required

• 3+ years of experience in case management, population health, or care coordination

Preferred

• Registered Nurse (RN) or a degree in social work, public health, or a related field.

Knowledge Base

• Experience managing relationships with outsourced vendors or external partners (preferred).
• Knowledge of healthcare regulations, value-based care models, and risk stratification.
• Excellent interpersonal, communication, and organizational skills.
• Proficiency with electronic health records (EHRs), care management software, and data reporting tools.

RESPONSIBILITIES / FUNCTIONAL JOB DESCRIPTION

• Case Management:
• Identify, engage, and manage patients with complex medical, behavioral, and social needs across populations.
• Conduct comprehensive assessments to determine patient needs and develop individualized care plans.
• Monitor patient progress, promote adherence to care plans, and facilitate transitions of care.
• Collaborate with internal care teams, physicians, social workers, and community resources to deliver coordinated services.
• Utilize health data analytics tools to stratify patient risk and target interventions effectively.
• Liaison Functions:
• Serve as the primary point of contact between the organization and outsourced care management vendors.
• Coordinate meetings, share updates, address operational concerns, and ensure smooth communication channels.
• Monitor outsourced company performance metrics and quality indicators to ensure contractual obligations and quality standards are met.
• Escalate issues to leadership as needed, propose solutions, and participate in vendor evaluations.
• Ensure that outsourced partners comply with organizational policies, HIPAA regulations, and healthcare best practices.
• Program Development & Reporting:
• Support the design, implementation, and refinement of population health initiatives.
• Analyze outcomes data to measure program effectiveness and recommend improvements.
• Prepare reports and dashboards for leadership highlighting key performance indicators (KPIs) and patient outcomes.
• Participate in quality improvement initiatives aimed at enhancing care delivery

DESIRED KNOWLEDGE, SKILLS & ABILITIES

• Strong clinical assessment and critical thinking skills.
• Ability to manage multiple priorities and projects simultaneously.
• Knowledge of social determinants of health (SDOH) and community resources.
• Skilled in building collaborative relationships across departments and organizations