Clinical Accountable Care Team Lead - Integrated Care Team; ICT

Minimum Qualifications:

Master’s degree from an accredited Nurse Practitioner program or Physician Assistant program primary care, home health, internal medicine, or geriatric clinical settings.

A minimum of three (3) years of relevant experience, including direct practicing experience in

Provides leadership for UTMB’s value-based care initiatives across primary care, surgical, and specialty services, with responsibility for advancing the transition from a fee-for-service model to a value-driven approach. Collaborates with UTMB Health medical staff and population health teams to drive performance against established government programs, commercial contracts, and population health quality metrics. Oversees care delivery strategies focused on improving quality outcomes, strengthening care coordination, and implementing preventive interventions to reduce total cost of care.

This is a full-time 1 FTE position. The Clinical Accountable Care Team Lead is expected to maintain a 0.5 clinical FTE (cFTE) to be active in clinical duties, and the other 0.5 FTE dedicated to administrative, operational, and leadership responsibilities in support of UTMB’s value-based care and population health initiatives.

• Systematically analyze patient data and electronic medical records (EMR) to identify and address missing preventative screenings, vaccinations, essential lab checks and providing education to patients on available resources or action plans.
• Oversee, coordinate, and create implementation plans that ensure the successful execution of one of these designated programs:
• Enhancing the Annual Wellness Visit (AWV) program and the Medicare Shared Savings Program through the oversight of AWV staff nurses to target and achieve set program goals. This includes a strong focus on risk assessment, cognitive evaluations, and socioeconomic risk factor identification.
• Implementation and ensure precise documentation of patient diagnoses with high specificity using Hierarchical Condition Category (HCC) coding to support accurate risk adjustment and appropriate resource allocation.
• Create and manage individualized care plans for patients with multiple comorbidities, such as Congestive Heart Failure (CHF), Chronic Obstructive Pulmonary Disease (COPD), and Diabetes in support of goals set within the MSSP and other value-based care programs
• Create processes and provide critical support for patients requiring higher levels of care during transitions, ensuring timely post-discharge follow-ups (via telehealth or in-person) when clinic visits are not feasible, thereby reducing readmissions.
• Conduct ongoing medication reconciliation to identify and mitigate polypharmacy risks, reduce adverse drug events, and optimize prescription regimens.
• Utilize telehealth and virtual evaluations to effectively triage patient needs, minimizing preventable Emergency Department (ED) visits and hospital admissions.
• Maintain effective communication with Nurse Care Managers, Social Workers, Pharmacists, Community Health Workers, patients, and payers to holistically address social determinants of health, including issues like food insecurity and transportation barriers as appropriate.
• Facilitate seamless data flow and communication of consultation notes between primary care and specialty clinics, ensuring integrated patient care.
• Monitor patient referrals, specialist consultations, diagnostic testing, and follow-up care to ensure continuity of services.

Actual salary commensurate with experience.

On-site, Monday through Friday, 8am to 5pm, and as needed on occasion.

UTMB Health strives to provide equal opportunity employment without regard to race, color, religion, age, national origin, sex, gender, sexual orientation, gender identity/expression, genetic information, disability, veteran status, or any other basis protected by institutional policy or by federal, state or local laws unless such distinction is required by law. As a Federal Contractor, UTMB Health takes affirmative action to hire and advance protected veterans and individuals with disabilities.