Overview Population Health Care Manager (BSN Highly Preferred)
Work Arrangement: Regular
Location: Durham, NC, US, 27710
Date: Oct 3, 2025
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.
General Description of the Job
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
Manage a designated caseload to complete timely development, completion, and implementation of assessments, care plans, and interventions for identified patient population, considering health, social, physical environment, behavioral health, substance use, trauma, economic status, and education
Provide individualized treatment plans by accessing data from multiple sources (medical records, claims, program metric reports) to target recipients and providers for outreach, education, and intervention
Perform targeted interventions to assist patients with connection to primary care providers and other health care resources
Involve the patient and their support systems in the decision-making process using a patient-centric, collaborative partnership approach
Use teaching and learning theories to assist patients and families with the impact of chronic illness
Monitor quality and effectiveness of interventions with specific, measurable goals
Maintain timely documentation of all care management activity in Maestro and other relevant systems
Communicate and coordinate with care team members to minimize fragmented care and foster appropriate utilization of services
Facilitate interdisciplinary communication among care team members and interface with providers across the care continuum
Provide on-site, community, and telephonic outreach to patients, providers, and community stakeholders
Connect with patients in various settings, including homes, community agencies, clinics, and through telehealth
Participate in quality assurance/performance improvement activities
Provide feedback to Team Lead, management, and executive leadership to enhance negotiations with payers and address gaps in care
Develop and maintain positive relationships with internal and external customers
Perform 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: LCSW, LCAS, or 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; it should not be construed as a declaration of the total duties of any position. Employees may be directed to perform job-related tasks other than those listed.
Duke University is an Affirmative Action/Equal Opportunity Employer committed to 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 collaborative, diverse, and inclusive community. All members of the 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. Reasonable accommodation requests will be provided by each hiring department.
Nearest Major Market: Durham
Nearest Secondary Market: Raleigh
Read more about Duke’s commitment to affirmative action and nondiscrimination at hr.duke.edu/eeo.