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Population Health Specialist- AMH+

Company: Nurse.com
Location: Durham
Posted on: September 20, 2023

Job Description:

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.Location:

Durham, North Carolina

Work Hours:


General Description

The Population Health Specialist will develop, implement, and evaluate comprehensive patient plans to ensure that patients receive appropriate overall medical care, therapy and training services, in an effort to enable their recovery or management of complex, chronic health conditions. The Population Health Specialist is responsible and accountable for supporting clinical expertise for specific complex patient populations. This role will perform supporting clinical disease management, assessment of disease states and utilization, care plan development and facilitation, referral to appropriate levels of care, etc. The Population Health Specialist functions as an integral part of an interdisciplinary team, ensuring excellence in patient care, in an effort to achieve optimal clinical outcomes through a seamless model of access and care. Focus on improving transitions in care for patients, physicians, family and community. Patient base consists of patients who are sub-optimal users of healthcare and/or management of chronic disease. Identify any barriers to proper utilization and determine best steps for following treatment recommendations, as well as providing resource/benefit education, counseling and self-care processes. Focus on improving transitions in care for patients, physicians, family and community. The Population Health Specialist will work as an integral part of an interdisciplinary team, ensuring excellence in patient care, in an effort to achieve optimal clinical outcomes through a seamless model of access and care.

Duties and Responsibilities

  • Administer, interpret, provide both verbal and written recommendations on improving accuracy and sustainability of policies and identified workflows staying within accreditation standards.
  • Be able to contribute substantially and/or co-facilitate multi-disciplinary report out teams to promote a healthy understanding of identified opportunities, improvement and/or highlight noted competences; developing and supporting partnerships to broaden PHMO responses and approaches to both internal and external audits.
  • Review and evaluate Admission, Discharge and Transfer (ADT) electronic alerts, electronic medical record notes or other patient trend data. Use communication systems and quality improvement tools to evaluate and support accomplishing noted needs identified.
  • Assess the educational needs of the staff and stakeholders as it relates to the care management process explore.
  • Monitor access to care management services, and treatment modality reliability to support high quality care.
  • Participate in quality/performance improvement projects and provide presentations of outcomes in various group settings, including provider and practice meetings, as needed.

    Knowledge, Skills and Abilities

    The work activity and patient acuity levels can create a stressful atmosphere, therefore individuals successful in this job are: -- Organized and motivated by a fast-paced environment -- Able to manage multiple tasks/projects simultaneously -- Proficient in review and assess needs quickly -- Strong with the use of computer software tools and data files -- Comfortable with continuous change and self-initiating -- Able to complete documentation in a quick and efficient manner (will be in legal medical record and other software systems developed for care management and population based program metrics)

    Level Characteristics

    Additional job expectati ons include the ability to:-- Maintain strict confidentiality-- Promot e programs and services to community-- Build effective and trusting rel ationships with patient/peers-- Use motivational interviewing and activ e-listening skills whenassessing patient conditions, problems and intere sts-- Use conflict-resolution skills when reachingconsensus about plans of care and treatment decisions-- Demonstrate confidence, compassion, p olitical savvy, as well asattention to detail to apply these skills as d ecisions dictate-- Use data to analyze trends andto verify data

    Minimum Qualifications


    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.

    Nearest Major Market: Durham

    Nearest Secondary Market: Raleigh

    Apply now

Keywords: Nurse.com, Durham , Population Health Specialist- AMH+, Healthcare , Durham, North Carolina

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