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.
The Population Health Care Manager is respo nsiblefor clinical expertisefor specific complex and/or rising risk pati entpopulations with adesign to meet specific contractual and program rel atedrequirements.This role will perform disease management, assessment o fdisease, careplan development and facilitation, referral to appropriate levels ofcare, etc. The rolefunctions as an integral part of aninterdis ciplinary team, ensuring excellence with transitions of care toachieve o ptimal clinical outcomes through a seamless model of access andcare. Foc us on improving the health status and care for individuals withchronic c onditions with complex medical, mental health and psychosocialissues.
Coordinate and facilitate timely impleme ntation of assessments, careplans, and appropriate interventions for id entified patient populationto determine patient health, social situation ,physical environment,mental health, substance use, expressed trauma, ec onomic status, andeducation to patients while exercising discretion andi ndependentjudgment; following established policies and procedures.Provid e individual treatment to address barriers and identified concernsby acc essing systematically identified data from multiple sources suchas patie nt medical records, claims, and program metric reports to targetrecipien t(s) and provider(s) for outreach, education, and intervention.Performta rgeted interventions to assist patients with connection toprimary carepr oviders and other health care resources.Involve the patient and theirsup port systems (i.e. caregiver, family,etc.) in the decision-making proces s. Use a patient-centric,collaborative partnership approach to assist th e patient with improvedself-management and identifying barriers by addre ssing the totalindividual, inclusive of medical, psychosocial, behaviora l, andspiritual needs.Utilize proven processes to measure a patientsunde rstanding andacceptance ofthe proposed plan(s), his/her willingness to c hange, andhis/her support to maintain health behavior change. Apply teac hing andlearning theories to assist patients and families with physicala ndemotional impact of body changes and chronic illness. Monitor qualitya nd effectiveness of interventions to the population by setting longterma nd/or short-term specific, measurable goal(s).Electronically documentall activity in Maestro, and other documentationsystems relevant to theposi tion.Communicate and coordinate with all provider(s) and member(s) of th ecare team as needed to minimize fragmented care and foster appropriateu tilization of services. This will include, navigating transitions ofcare generally from hospital to home or community facilities.Facilitateinter disciplinary communication to include specialists, PCP,RN, psychiatrist and other keyproviders. Interface with key providers(e.g. discharge plan ners, social workers, physicians, psychiatrist etc.)within the hospital, primary care practices, public health and socialservice departments, as well as mental health agencies and othercommunity resourcesto assure th at patients are linked to and engaged inservices.Provide on-site,communi ty, and telephonic outreach to patients,providers, and communitystakehol ders assisting with identificationoftreatment history, diagnoses and pa tient care components both internallyand externally to ensure that servi ces provided are sensitive to theneeds of individual patients and take i nto account ethnic and culturalbackgrounds. This positionmay require hom e visits based on businessrules and clinical need of identifiedpatient p opulation.Provide feedback to TL, management, and executive leadership t hat willenhance negotiations with payers,improve caremanagement, and/ora ddress gaps in care.Develop and maintain positive relationshipswith cust omers internal andexternal to Duke Health System.
Bachelor's degree in business, behavioral/social sciences, public health or related population health field.
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
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.
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.
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.
As a world-class academic and health care system, Duke Health strives to transform medicine and health locally and globally through innovative scientific research, rapid translation of breakthrough discoveries, educating future clinical and scientific leaders, advocating and practicing evidence-based medicine to improve community health, and leading efforts to eliminate health inequalities.