Population Health Care Manager-Embedded at LCHC (BSN Highly Preferred)
Duke University Health System
Location: Durham, North Carolina
Internal Number: 192728
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 responsible for clinical expertisefor specific complex and/or rising risk patient p opulations with adesign to meet specific contractual and program related requirements.This role will performdisease management, assessment of d isease, careplan development and facilitation, referral to appropriate l evels ofcare, etc. The role functions as an integral part of aninterdisc iplinary team, ensuring excellence with transitions of care toachieve optimal clinical outcomes through a seamless model of access andcare. Focu s on improving the health status and care for individuals withchronic co nditions with complex medical, mental health and psychosocialissues.
Population Health Management Office - physical location within Lincoln Community Health Center located in Durham, North Carolina.
Lincoln Community Health Center is a primary care clinic in Durham offering a wide variety of services in one convenient location. They provide personalized care for adults and children in a comfortable environment.
Hours: Monday-Friday 8am-5pm
General Description of the Job Class
The Population Health Management Office (PHMO) seeks a Population Health Care Manager whose primary physical location will be at Lincoln Community Health Center. This Population Health Care Manager is an integral part of an interdisciplinary team that includes PHMO and Lincoln Community Health Center team members. This role is focused on supporting individuals to achieve optimal health outcomes through a seamless model of access and care. This position performs key functions of care management in-person in clinic, virtually, and telephonically, including:
Identifies and addresses medication discrepancies, patient understanding of their prescribed medication dosing/regimen, barriers to patient obtaining their prescribed medications, etc.
Screens for social drivers of health and helps connect patients to community-based resources
Educates and reinforces hospital follow-up plan of care
Identifies and addresses barriers to health care and provides connection to the appropriate resources
Communicates pertinent information with the patient's health care team
Disease management, assessment of disease, care plan development and facilitation, referral to appropriate levels of care, etc.
Bachelor's degree in a clinical field such as Nursing, Counseling, Social Work, Therapy, Allied Health, or community health related fields.
3 years of clinical experience required.
Degrees, Licensures, Certifications
Must have a current license in at least one ofthese areas: current or compact RN licensure in the state of North Carolina, current licensure as a licensed clinical social worker by the NC Social Work Certification and Licensure Board, current licensure as a Licensed Professional Counselor by the state of NC, or current licensure as a Licensed Addiction Specialist by the state of North Carolina. Requires ACM or CCM certification within 3 years of hire date or by December 31, 2020.
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