Population Health Program Manager

Working title: Population Health Program Manager

Classification title: Program Manager 3

Division: Community Health Center                   

Program: Main Campus

Reports to: Sr Director of Health Center Operations Support

FLSA status: Exempt: Full-time

Schedule: Monday-Friday

Wage Range: $71,797 to $103,318 annually depending on number of years of transferrable experience and internal equity

RiverStone Health:

Serving the Yellowstone County community and south-central Montana for over 50 years, RiverStone Health is an essential provider of personal and public health services. Health, Education, Leadership and Protection – HELP is what we do. 

From medical, dental and behavioral healthcare; home care and hospice; public health services like immunizations, WIC, health promotion and restaurant inspections; and educating the next generation of health professionals, our expertise spans all ages and stages of life.  Underlying principles of access, affordability, compassion and quality in all interactions, RiverStone Health improves life, health and safety for all of the communities we serve.

Job Summary:

The Population Health Program Manager provides strategic and operational leadership for population health and care management services across clinic sites. This role is responsible for the development, oversight, and continuous improvement of programs that support patient engagement, care coordination, management of high-risk populations, and improved health outcomes across the continuum of care.

The position oversees multidisciplinary care management and patient support teams including general care management, behavioral health care management, pediatric care management, transitions of care, school-based services, healthcare for the homeless, and insurance enrollment and resource navigation services.

The Population Health Program Manager partners with clinical, operational, and quality leadership to identify population health priorities, reduce barriers to care, improve quality outcomes, and strengthen care coordination and patient engagement strategies. This role ensures alignment with Patient-Centered Medical Home (PCMH) principles, HRSA requirements, and organizational goals related to access, quality, and equitable patient outcomes.

This role integrates care management with population health initiatives by partnering with clinical leadership and quality management to identify high-risk populations, improve care engagement, enhance care coordination, and drive performance on clinical quality metrics. The manager ensures alignment with Patient-Centered Medical Home (PCMH) principles, HRSA requirements, and organizational goals to improve access, quality, and patient outcomes.

Essential Functions/Major Duties and Responsibilities: 

A.   Population Health & Care Management Program Duties                             95%

• Collaborate with clinical and operational leadership to identify population health priorities and develop strategies to improve preventive care, chronic disease management, care engagement, and equitable health outcomes.
• Provide system-wide leadership and oversight of all care management services across clinic sites, ensuring standardized, efficient, and high-quality care coordination processes.
• Oversee multidisciplinary care management teams, including general care management, behavioral health, pediatrics, transitions of care, school-based services, healthcare for the homeless, and insurance enrollment/resource navigation.
• Develop, implement, and continuously improve care management workflows, policies, and standard operating procedures across programs and sites.
• Support risk stratification, registry development, and proactive care engagement strategies to identify and manage high-risk and rising-risk patient populations.
• Partner with the Quality Improvement to develop and implement targeted care management strategies to improve outcomes, support performance improvement initiatives tied to clinical quality measures (e.g., UDS, HEDIS, value-based care metrics).
• Collaborate with clinic leadership to align care management strategies with clinical priorities, driving improved care coordination, reduced gaps in care, and enhanced patient engagement.
• Lead or support quality improvement initiatives, including PDSA cycles and innovation projects related to care management and patient engagement.
• Ensure standardized, high-quality care coordination across the continuum (outpatient, inpatient, ED, and community-based settings), including transitions of care and support for complex, chronic, behavioral health, and pediatric populations to improve engagement and outcomes.
• Oversee processes to identify and address social determinants of health, including coordination with community resources and development of patient education related to insurance coverage and available services.
• Utilize data tools (e.g., EHR registries, dashboards, internal reporting) to monitor program performance, patient outcomes, and care management impact, and regularly review and act on performance and utilization reports.
• Provide leadership and supervision to care management staff, including hiring, onboarding, training, performance management, and professional development, while establishing clear expectations for productivity, documentation, and patient engagement.
• Collaborate with clinic managers to provide orientation and ongoing training to their Care team staff.
• Lead and facilitate regular staff meetings, training sessions, and cross-functional collaboration efforts to ensure effective communication, team building, and ongoing staff development.
• Prioritize and allocate workload to achieve maximum efficiency and productivity.
• Ensure compliance with HRSA, PCMH, FTCA, and other regulatory and grant requirements by overseeing documentation standards, care management billing and reporting workflows, program policies and procedures, and participation in risk management activities, including incident reporting, investigation, and follow-up.
• Address client and service provider complaints and resolve complex issues.  Direct complaints and incidents to Program Director after resolution process.
• Participate in budget planning and resource allocation for care management services.
• Serve as a key liaison across care management, clinical teams, leadership, and community partners, facilitating effective communication, collaboration, and coordination of services.
• Build and maintain effective relationships with other RiverStone Health service lines to ensure awareness and coordination of services and to foster confidence in the clinic services.
• Attend meetings, conferences, workshops, and training sessions and reviews publications and other training materials to become and remain current on principles, practices, and new developments in care coordination.

Non-Essential Functions/Other duties as assigned                            ≥5%

• Perform other duties as assigned in support of RiverStone Health’s mission and goals.

Education and Experience: 

Minimum Qualifications

• Bachelor’s degree in Nursing, Social Work, Public Health, or a related field OR equivalent combination of education and experience

• 1-2 years of supervisory or leadership experience

• 3-5 years of experience with population Health, Care Management, care coordination, social work or related healthcare services

• Experience working in a healthcare setting (e.g., FQHC, primary care, hospital, or community-based care

Preferred Qualifications:

• RN licensure preferred

• care management billing, insurance enrollment, and healthcare coverage programs (e.g., Medicaid, CHIP, Marketplace)

• Experience with population health strategies, risk stratification, registry management, and care management program development

• Experience leading multidisciplinary teams and cross-functional initiatives

Required Certificates, Licenses, Registrations:

• Certification as an Application Counselor (CAC) or completion within 90 days of employment.

Knowledge, Skills, and Abilities: 

• Knowledge of population health strategies, risk stratification, and care management models within an FQHC setting
• Experience using data and analytics tools (e.g., Azara, Power BI, EHR registries) to drive decision-making
• Understanding of value-based care, quality metrics (UDS/HEDIS), and care management billing requirements
• Proficiency with Microsoft Office and relevant care management/analytics tools (e.g., EHR registries, Power BI).
• Ability to work collaboratively and maintain a positive work environment.
• Ability to understand and adhere to required administrative policies and procedures.
• Excellent communication skills to ensure efficiencies and quality customer service.

Customer Service Excellence: 

• Doing things right the first time

• Making people feel welcome

• Showing respect for each customer

• Anticipating customer needs and concerns

• Keeping customers informed

• Helping and going the extra mile

• Responding quickly

• Protecting privacy and confidentiality

• Demonstrating proper telephone etiquette

• Taking responsibility for handling complaints

• Being professional

• Taking ownership of your attitude toward Service Excellence.

Supervision: 

• Supervision of care management staff, 11 FTE

Physical Demands and Working Conditions:

• Work is mainly performed in a clinic setting.

• Some travel to satellite clinic sites and community outreach events

• Create and maintain a safe/secure working environment by adhering to safety, security, and health requirements. Integrates injury, illness, and loss prevention into job activities by attending any necessary training and implementing best practices.

Freedom to Act & Decision Making:

• Utilizes independent judgment.

• Decisions directly affect the quality of services provided to the public.

Communications & Networking:

• Daily written and verbal communication with patients, clients and other staff.

• Work directly with other team members to provide quality customer service for patients and customers.

 Budget & Resource Management: