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.
Population Health Care Manager is responsible for delivering clinical expertise to manage healthcare needs of specific patient populations across the continuum of care with the 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. The focus is on improving 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, medical, behavioral health, and psychosocial needs by performing care management and care coordination functions within the Education and Quality Team.
Preferred Experience
Quality Assurance, Auditing, Regulatory Compliance, and Training and Education.
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 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 systematically identified 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 (i.e., caregiver, family, etc.) in the decision‑making process.
Utilizes proven processes to measure a patient’s understanding and acceptance of the proposed plan(s).
Applies teaching and learning theories to assist patients and families with physical and emotional impact of body changes and chronic illness.
Monitors quality and effectiveness of interventions to the population by setting short‑ and long‑term specific, 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, including navigating transitions of care from hospital or facility to home or community facilities.
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 to identify treatment history and ensure services are sensitive to individual needs, including ethnic and cultural backgrounds.
Connects with patients and other care team members in a variety of settings, including patient homes, community agencies, primary care practices, telephone and other virtual platforms. This position may require home visits based on business rules and clinical need.
Participates in quality assurance/performance improvement activities as requested.
Provides feedback to Team Lead, management, and executive leadership to enhance negotiations with payers and improve care management.
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
Education: Bachelor’s degree in Nursing or a Master’s degree that supports licensure by the NC Board of Licensed Clinical Mental Health Counselors (e.g., counseling, social work, allied/behavioral health).
Experience: 3 years of relevant clinical experience required.
Licensure and Certification:
BSN candidates must have current or compact RN licensure in the state of NC.
Master’s degree candidates (e.g., psychology, social work, counseling, or related behavioral health program) must have 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.
Effectively able to manage multiple priorities in a fast‑paced and evolving environment.
Demonstrates basic computer skills to complete job functions.
Distinctive Characteristics
The intent of this job description is to provide a representative and level of the types of duties and responsibilities that will be required of positions given this title and shall not be construed as a declaration of the total of the specific duties and responsibilities of any particular position. Employees may be directed to perform job‑related tasks other than those specifically presented in this description.
Equal Opportunity Statement
Duke University is an affirmative action/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 veteran status.
Duke aspires to create a community built on collaboration, innovation, creativity, and belonging. Our collective success depends on the robust exchange of ideas—a 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.
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.