Medical Practice Other - Baystate Health

Req#: R23491
Category(s): Allied Health Clinical Professional, Medical Practice Other
Full Time / Part Time: Full-Time

Under the direction of and in partnership with the Chief of Clinical Integration, the Director of Population Health & Clinical integration is accountable for the strategic and operational planning and execution of Baystate Health's Population Health and clinical integration strategies needed for success in value based care and achieving orchestrated access goals.  This includes oversight and management of Baystate’s post-acute network, clinically integrated care model design to achieve access optimization, medical complexity program success, direct supervision of the BeHealthy ACO medicaid ambulatory care management teams, and medical management programming needed for success in value-based care and population health.

In doing so, he/she works to assure a comprehensive, cohesive, and coordinated approach to the care of patients over time, in multiple environments, and across the entire spectrum of healthcare services delivery both within and outside of BH. He/She provides leadership in developing, planning, organizing, implementing, and evaluating continuum of care services respective to the goals of access, clinical quality, value, and satisfaction and works with clinical leadership across the health system and other outside entities to align strategies and tactics.

Along with the Director of Quality and Medical Management, he/she operationalizes programs aligned with the key drivers of success in value-based care including programs designed to manage and optimize medical management opportunities, address appropriate risk adjustment, quality management, and align programs to maximize success in value-based care.

The Director oversees ambulatory care coordination activities within Baystate’s population health infrastructure and is responsible for the strategic design and implementation of clinical population health services delivered by BH and in coordination with other partner entities (e.g., Disease Management, Complex Case Management, Wellness/HEDIS STARs and Transitions of Care).

The Director will oversee the strategic direction and clinical operations of a robust Care Management team dedicated to the BeHealthy ACO that focuses on coordinating the overall care for identified patients at and among various clinics and physician practice sites, and across key partners such as post-acute, community, Behavioral health and LTSS partners.  This is accomplished through network development with community partners and the direct oversight of practice-based and centralized teams of a Nurse Care Managers, Care Coordinators, Social Workers, Recovery Coaches, and Community Health workers.  He/She will oversee the development of standard processes and workflows for care management activities that meet contractual requirements and include integration into the health systems population health platform.


  • Ability to lead large scale transformational change in health care at the organizational/system level and work effectively with all levels within and outside the organization, individual and team, across disciplines and geography
  • Provides strategic oversight and management of population health service teams within BH including ambulatory care management (e.g., Disease Management, Complex Case Management, Wellness/HEDIS STARs and Transitions of Care). He/She will provide direct oversight to the BeHealthy ACO care management teams and will provide integrative leadership for partner programs providing care to BH patients.  This includes ensuring compliance with contractual obligations for BeHealthyACO care management activities.
  • Directs focused care management and disease management interventions targeted to improve patient and provider satisfaction, decrease costs, maximize quality and improve clinical outcomes.  This includes the ability to develop appropriate protocols and guidelines
  •  Develop and implement educational and professional development programs and curriculum across care management program staff (care managers (RN), community health workers, health coaches) to ensure continuing professional growth/advancement  
  • Development and management of clinical integration and preferred provider networks for BH with key network partners including home health agencies, skilled nursing partners, community based organizations as well as primary and specialty care providers.
  • Orchestrates the development, implementation, and outcomes measurement of clinical programming and tactics to meet population health medical management targets (ie readmission strategies, transitions in care)
  • Management of Baystate Ambulatory Medical Complexity (RAF) team including development and implementation of strategies and processes to facilitate addressing chronic disease gaps and appropriate diagnosis capture. This includes clinician engagement and education, data analytics, process improvement, and workflow optimization across all lines of at risk business
  • Along with the Chief of Clinical Integration, works collaboratively with service line clinical leaders and population based medical directors to create and execute standardized, cross continuum, technology-enabled organized models of chronic disease care in support of executing on a vision of orchestrated access to health
  • Providers direct strategic and program oversight to the Mobile Health Equity Program (Wellness on Wheels) to deliver integrated health equity programming throughout the tri-county region. This includes the training of allied health professionals on delivering community health to underserved communities through the practical application of a curriculum of cultural humility and community outreach and engagement
  • Creates and facilitates the interdisciplinary team process to ensure comprehensive care delivery and coordination across the continuum for patients and their families
  • Act as a liaison between care management managers at physician practices, facilities, and managed care organizations to resolve continuum of care issues related to patient care.  Develop and maintain positive working relationships with and between physicians, their clinical office staffs, the clinical staffs of managed care plans and PHOs (Baycare), the skilled nursing facility network, home health network, behavioral health and other community partners..
  • Analyze population health data and trends, including quality and efficiency reporting, to design appropriate reporting and develop appropriate strategies to improve performance     
  • Demonstrated program/project management and data analysis skills in population health management, including population health analytics, disease and medical management, and financial optimizatio

Required Experience:

Minimum of 10 years related job experience required.

Healthcare experience with Health system, Accountable Care Organizations (ACOs), or Physician Hospital Organizations (PHOs) in value-based care agreements.

Experience in the redesign of systems and care management is required. Knowledge of chronic conditions, evidence-based guidelines, prevention, and wellness. Knowledge and experience with performance excellence and lean practices to improve quality and processes  

Preferred Experience:

Experience with medical management and data analytics to support population health. Experience with integrating data and technologies into clinical programming and workflows.


Must be comfortable operating in a collaborative, matrixed leadership environment. Must possess strong organizational skills

Ability to understand and analyze quality and efficiency data.  Can multi-task, prioritize own work and coordinate the work of other departments within and outside of the organization to meet population health goals and integrate care transformation.

Capacity to work strategically, closely, and effectively with practice leaders and physicians, care managers/coordinators, hospital administration, and information technology teams.

Expertise and demonstrated success with large scale change management initiatives.

Demonstrated presentation skills, including the ability to communicate complex concepts in an effective manner.

Capacity to facilitate meetings with groups of various size and knowledge. 

Ability to handle situations which often require the use of tact and diplomacy

Able to operationalize care model redesign within a matrixed environment including clinical teams, ambulatory operations, finance, payors, and IT

Understanding of how to operationalize on key drivers of value-based care success including medical management, financial risk methodologies, risk adjustment capture, HEDIS quality outcomes,and care management.

You Belong At Baystate

At Baystate Health we know that treating one another with dignity and equity is what elevates respect for our patients and staff. It makes us not just an organization, but also a community where you belong. It is how we advance the care and enhance the lives of all people.



Master of Science (Required)


Registered Nurse – State of Massachusetts

Equal Employment Opportunity Employer

Baystate Health is an Equal Opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, marital status, national origin, ancestry, age, genetic information, disability, or protected veteran status.

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