Overview Duke Connected Care , a community-based, physician-led network, includes a group of doctors, hospitals and other healthcare providers who work together to deliver high-quality care to Medicare Fee-for-Service patients in Durham and its surrounding areas.
Job Description The Population Health Care Manager is responsible for delivering clinical expertise to manage health care needs of specific patient populations across the continuum of care with a goal of improving patient health outcomes and reducing unnecessary utilization and cost. This role functions as an integral part of an interdisciplinary team and a patient’s care team to optimize clinical outcomes through a seamless model of transitions, access, and care. This role focuses on improving the health status and connection to resources, preventive care, hospital follow-up, and ongoing healthcare for individuals with chronic health conditions as well as addressing frequent hospital and emergency department utilization, and medical, behavioral health, and psychosocial needs by performing care management and care coordination functions in a variety of settings that include a patient’s home, community, and clinic.
Responsibilities Disease management and chronic disease support
Timely completion of clinical assessment and patient-centered care plan development, facilitation, and implementation
Transitional Care Management / care transition support inclusive of functions of placement into the right setting of care (e.g., skilled nursing, assisted living, home with caregiver support)
Assessment of and connection to resources and treatment for health, social, and behavioral needs
Patient activation and coordination for quality and preventive care gap closure
Assistance with and completion of medication reconciliation, access, education, and adherence
Manages a designated caseload to complete timely development, completion, and implementation of assessments, care plans, and appropriate interventions for identified patient population
Provides individualized treatment plans to address barriers and identified concerns by accessing data from multiple sources such as patient medical records, claims, and program metric reports
Performs targeted interventions to assist patients with connection to primary care providers and other health care resources
Involves the patient and their support systems in the decision-making process using a patient-centric, collaborative approach
Utilizes teaching and learning theories to assist patients and families with the physical and emotional impact of body changes and chronic illness
Monitors quality and effectiveness of interventions by setting measurable goals
Maintains timely documentation of all care management activity in Maestro, and other documentation systems relevant to the position
Effectively communicates and coordinates with appropriate care team members to minimize fragmented care and foster appropriate utilization of services
Facilitates interdisciplinary communication among care team members and interfaces with key providers across the care continuum
Provides on-site, community, and telephonic outreach to patients, providers, and community stakeholders
Connects with patients and other care team members in a variety of settings, including patient homes, community agencies, and primary care practices
Participates in quality assurance/performance improvement activities as requested
Provides feedback to Team Lead, management, and executive leadership to enhance negotiations with payers and address gaps in care
Develops and maintains positive relationships with customers internal and external to Duke Health System
Provides other related duties incidental to the work described herein
Required Qualifications at this Level Education :
Bachelor's degree in Nursing or Master’s degree that supports licensure by the NC Board of Licensed Clinical Mental Health Counselors (i.e., counseling, social work, allied/behavioral health).
Experience :
3 years of relevant clinical experience required.
Degrees, Licensure, and/or Certification :
Candidates with a BSN must have current or compact RN licensure in state of NC
Candidates with a Master’s degree (e.g., psychology, social work, counseling, or related behavioral health program) must have a current licensure by one of the following NC Boards: Licensed Clinical Social Worker (LCSW), Licensed Clinical Addiction Specialist (LCAS), or Licensed Clinical Mental Health Counselor (LCMHC)
All candidate/employees require a case management certification (ACM, CCM, or ANCC) within 3 years of hire
Knowledge, Skills, and Abilities :
Exceptional verbal/written communication and facilitation skills
Self-driven and able to work effectively in a self-directed role
Excellent problem-solving skills
Ability to manage multiple priorities in a fast-paced and evolving environment
Demonstrates basic computer skills to complete job functions
Distinguishing Characteristics of this Level
The intent of this job description is to provide a representative level of the duties and responsibilities that will be required of positions given this title and shall not be construed as a declaration of the total duties and responsibilities of any particular position. Employees may be directed to perform job-related tasks other than those presented.
EEO Statement
Duke University is an Affirmative Action/Equal Opportunity Employer committed to providing employment opportunity without regard to age, color, disability, gender, gender expression, gender identity, genetic information, national origin, race, religion, sex, sexual orientation, or veteran status. Duke aspires to create a community built on collaboration, innovation, creativity, and belonging. All members of our community have a responsibility to uphold these values.
Essential Physical Job Functions
Certain jobs at Duke University and Duke University Health System may include essential job functions that require specific physical and/or mental abilities. Additional information and provision for requests for reasonable accommodation will be provided by each hiring department.
POPULATION HEALTH CARE MANAGER
Duke is an Equal Opportunity Employer committed to providing employment opportunity without regard to an individual\'s age, color, disability, gender, gender expression, gender identity, genetic information, national origin, race, religion, sex, sexual orientation or military status.
Duke aspires to create a community built on collaboration, innovation, creativity, and belonging. Our collective success depends on the robust exchange of ideas—an exchange that is best when the rich diversity of our perspectives, backgrounds, and experiences flourishes. To achieve this exchange, it is essential that all members of the community feel secure and welcome, that the contributions of all individuals are respected, and that all voices are heard. All members of our community have a responsibility to uphold these values.