The Program Manager, Integrated Care is responsible for overseeing the Patient Centered Primary Care Home (PCPCH) Program, ensuring its objectives are achieved. This role manages the preparation and execution of site visits for program verification, evaluates program performance, and reports on activities. Additionally, this role will participate in cross-functional teams to develop and execute initiatives that foster collaboration across diverse care teams (medical, behavioral health, nursing, pharmacy, etc.) to improve patient outcomes, enhance care coordination, and support value-based care objectives. The role also involves utilizing appropriate project management tools to track timelines, tasks, milestones, and communication planning, while coordinating project meetings to ensure alignment with project goals and tracking task completion.

Responsibilities: 

Serve as the subject matter expert for the PCPCH program, maintaining up-to-date knowledge of PCPCH standards and recognition criteria, and providing internal consultation and education as needed. Work closely with leadership to identify and remove operational barriers, recommend necessary resources, and ensure smooth communication across the PCPCH program. Facilitate the efficient flow of information to support program goals and drive successful outcomes. Oversee the completion and submission of Patient Centered Primary Care Home (PCPCH) applications, ensuring all required documentation is accurate and aligned with program standards. Collect and compile de-identified patient data and examples that demonstrate adherence to PCPCH quality measures, submitting them to the program as required for reporting purposes. Perform regular audits to assess ongoing adherence to PCPCH program requirements. Identify areas of non-compliance and work with teams to implement corrective actions, ensuring sustained compliance with program standards. Advise leadership on potential risks or barriers that could affect clinic performance and ratings in the PCPCH program. Offer proactive strategies and recommendations to mitigate these challenges and ensure successful program outcomes. Facilitate and prepare for PCPCH site visits, serving as the primary point of contact for the PCPCH Coordinator, gathering required data and documentation, and conducting site education to prepare clinic teams. Coordinate and schedule patient focus groups, employee and leadership meetings, and interviews for site visits. Provide detailed reports on the findings from site visits, highlighting areas of success and areas that require further verification. Collaborate with site teams to address these areas and ensure ongoing program compliance. Assist sites in identifying gaps and opportunities for improvement based on verification results and offer actionable recommendations and work closely with teams to implement improvements. Collaborate with site leadership to create an action plan to meet measure specifications or to address improvement opportunities identified during the site verification. Monitor progress and ensure the action plan is tracked and completed successfully. Work closely with the Director of Clinical Services to design and develop workflows, procedures, and standards that enhance care team integration, ensuring smooth and efficient patient care delivery aligned with PCPCH and integrated care team model. Assist in the development and implementation of projects focused on creating integrated healthcare practices across multiple disciplines, including medical, mental health, behavioral health, nursing, nutrition, pharmacy, and dental care, ensuring cohesive and collaborative patient care. Partner with the Clinical Informatics team to optimize the use of electronic health record (EHR) systems, ensuring they support integrated care workflows, enhance data sharing across care teams, and improve patient outcomes through streamlined information management in support of the PCPCH Program. Work closely with Director, Clinical Services to design and deliver targeted training programs for care teams and staff that reinforce best practices in integrated care, team-based care models, and value-based payment initiatives. Ensure the training enhances team collaboration, improves patient care, and supports organizational goals. Leverage Mosaic continuous process improvement tools to support and enhance PCPCH quality measure performance and ensure consistent achievement of care standards. Provide support and collaborate with community organizations to drive integrated care projects, ensuring alignment with the PCPCH model.

Work Experience: Two years’ experience in program management, preferably within integrated care or healthcare systems. Clinical work experience preferred.

Education, certification, and licensure: Bachelor’s degree preferred or equivalent life experience. Oregon Driver’s License required.   

Skills and Knowledge: Excellent communication and interpersonal skills, with the ability to lead and collaborate across diverse teams. Demonstrated ability to manage multiple projects and meet deadlines. Strong knowledge of integrated care models, team-based care, and value-based care principles. Excellent typing and computer skills and comfort with Microsoft Windows® operating system. EHR experience, EPIC experience a plus. Knowledge of health insurance plans, standard office policies and procedures. Understanding of healthcare regulations and compliance standards.

Who We Are:

Mosaic Community Health prides itself on being an innovative health system that pioneers unique and creative ways to provide and improve patient access to health care. Since our founding in 2002 we have proudly served insured and uninsured patients regardless of age, ethnicity, or income.

We focus on a holistic approach to patient care by incorporating behavioral health, pharmacy, and nutrition support to serve patients in the most meaningful way. At Mosaic Community Health, you will work with incredibly dedicated and mission-centered peers and be part of a dynamic team-based environment.

Mosaic Community Health offers more than just a job, it is a lifestyle. A lifestyle of serving others. A lifestyle of being an integral part of your community. A lifestyle that offers work/life balance. A lifestyle of enjoying the outdoors!