Population Health Care Manager-Complex Care Management

Duke Careers • Durham, NC

91d

About The Position

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. The Population Health Care Manager is responsible for clinical expertise for specific complex and/or rising risk patient populations with a design to meet specific contractual and program related requirements. This role will perform disease management, assessment of disease, care plan 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.

Requirements

• 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.
• Must have a current license in at least one of these 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, Current licensure as a Licensed Addiction Specialist by the state of North Carolina.
• Requires ACM or CCM certification within 3 years of hire date.

Responsibilities

• Coordinate and facilitate timely implementation of assessments, care plans, and appropriate interventions for identified patient population.
• Provide individual treatment to address barriers and identified concerns by accessing systematically identified data from multiple sources.
• Perform targeted interventions to assist patients with connection to primary care providers and other health care resources.
• Use a patient-centric, collaborative partnership approach to assist the patient with improved self-management.
• Utilize proven processes to measure a patient's understanding and acceptance of the proposed plan(s).
• Apply teaching and learning theories to assist patients and families with physical and emotional impact of body changes and chronic illness.
• Monitor quality 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.
• Facilitate interdisciplinary communication to include specialists, PCP, RN, psychiatrist and other key providers.
• Interface with key providers within the hospital, primary care practices, public health and social service departments.
• Provide on-site, community, and telephonic outreach to patients, providers, and community stakeholders.
• Provide feedback to TL, management, and executive leadership that will enhance negotiations with payers.
• Develop and maintain positive relationships with customers internal and external to Duke Health System.

What This Job Offers

• Education Level: Bachelor's degree
• Number of Employees: 5,001-10,000 employees