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 itssurrounding areas.
Occ Summary
The Population Health Care Manager is responsible for clinical expertise for specific complex and/or rising risk patient populations with adesign to meet specific contractual and program related requirements. This role will perform disease management, assessment of disease, careplan development and facilitation, referral to appropriate levels of care, etc. The role functions as an integral part of an interdisciplinary team, ensuring excellence with transitions of care to achieve optimal clinical outcomes through a seamless model of access and care. Focus on improving the health status and care for individuals with chronic conditions with complex medical, mental health and psychosocial issues.
Work Performed
Coordinate and facilitate timely implementation of assessments, care plans, and appropriate interventions for identified patient population to determine patient health, social situation, physical environment, mental health, substance use, expressed trauma, economic status, and education to patients while exercising discretion and independent judgment; following established policies and procedures. Provide individual treatment to address barriers and identified concerns by accessing systematically identified data from multiple sources such as patient medical records, claims, and program metric reports to target recipient(s) and provider(s) 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 (i.e. caregiver, family, etc.) in the decision-making process. Use a patient-centric, collaborative partnership approach to assist the patient with improved self-management and identifying barriers by addressing the total individual, inclusive of medical, psychosocial, behavioral, and spiritual needs. Utilize proven processes to measure a patients understanding and acceptance of the proposed plan(s), his/her willingness to change, and his/her support to maintain health behavior change. Emotional impact of body changes and chronic illness. Monitor teaching and learning theories to assist patients and families with phyuality and effectiveness of interventions to the population by setting long term and /or short-term specific, measurable goal(s). Electronically document all activity in Maestro, and other documentation systems relevant to the position. Communicate and coordinate with all provider(s) and member(s) of the care team as needed to minimize fragmented care and foster appropriate utilization of services. This will include, navigating transitions of care generally from hospital to home or community facilities. Facilitate interdisciplinary communication to include specialists, PCP, RN, psychiatrist and other key providers. Interface with key providers (e.g. discharge planners, social workers, physicians, psychiatrist etc.) within the hospital, primary care practices, public health and social service departments, as well as mental health agencies and other community resources to assure that patients are linked to and engaged in services. Provide on-site, community, and telephonic outreach to patients, providers, and community stakeholders assisting with identification of treatment history, diagnoses and patient care components both internally and externally to ensure that services provided are sensitive to the needs of individual patients and take into account ethnic and cultural backgrounds. This position may require home visits based on business rules and clinical need of identified patient population. Provide feedback to TL, management, and executive leaders hip that will enhance negotiations with payers, improve care management, and/or address gaps in care. Develop and maintain positive relationships with customers internal and external to Duke Health System.
Minimum Qualifications
Education
Bachelor's degree in business, behavioral/social sciences, public health or related population health field.
Experience
Work requires three years of experience in a business, behavioral/ social sciences, public health or related population health field. Sales and Marketing background, along with professional experience in Social Work, Disease Management, and experience working directly with Physicians and Advanced Practice Providers is strongly preferred.
Degrees, Licensures, Certifications
N/A
Duke 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.
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Essential Physical Job Functions: Certain jobs at Duke University and Duke University Health System may include essentialjob 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.
