Population Health Care Manager
Company: Duke Health
Location: Durham
Posted on: September 27, 2024
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. -Home Visits are required for this positionExternal
Candidates are eligible for a $10,000.00 Commitment Bonus paid over
2 yearsEmbedded at a Duke Outpatient Clinic -General Description
-The Population Health Care Manager is responsible for delivering
clinical expertise to manage health care needs of specific patient
populations across the continuum of care with a goal of improving
patient health outcomes and reducing unnecessary utilization and
cost. This role functions as an integral part of an
interdisciplinary team and a patient's care team to optimize
clinical outcomes through a seamless model of transitions, access,
and care. This role focuses on improving the health status and
connection to resources, preventive care, hospital follow-up, and
ongoing healthcare for individuals with chronic health conditions
as well as addressing frequent hospital and emergency department
utilization, and medical, behavioral health, and psychosocial needs
by performing care management and care coordination functions in a
variety of settings that include a patient's home, community, and
clinic. These functions include:
- Disease management and chronic disease support
- Timely completion of clinical assessment and patient-centered
care plan development, facilitation, and implementation
- Transitional Care Management/care transition support inclusive
of functions of placement into the right setting of care (e.g.,
skilled nursing, assisted living, home with caregiver support)
- Assessment of and connection to resources and treatment for
health, social, and behavioral needs
- Patient activation and coordination for quality and preventive
care gap closure
- Assistance with and completion of medication reconciliation,
access, education, and adherenceDuties and Responsibilities of this
Level
- Manages a designated caseload to coordinate and facilitate
timely implementation of assessments, care plans, and appropriate
interventions for identified patient population to determine
patient health, social situation, physical environment, behavioral
health, substance use, expressed trauma, economic status, and
education to patients while exercising discretion and independent
judgment.
- Provides 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. Performs targeted
interventions to assist patients with connection to primary care
providers and other health care resources.
- Involves the patient and their support systems (i.e. caregiver,
family, etc.) in the decision-making process. Uses a
patient-centric, collaborative partnership approach to assist the
patient with improved self-management and identifying barriers
through a "whole-person" approach, inclusive of medical,
psychosocial, behavioral, and spiritual needs.
- Utilizes proven processes to measure a patient's understanding
and acceptance of the proposed plan(s), his/her willingness to
change, and his/her support to maintain health behavior
change.
- Applies teaching and learning theories to assist patients and
families with physical and emotional impact of body changes and
chronic illness.
- Monitors quality and effectiveness of interventions to the
population by setting long term and/or short-term specific,
measurable goal(s).
- Maintains timely documentation of all care management activity
in Maestro, and other documentation systems relevant to the
position.
- Effectively communicates and coordinates with appropriate care
team members to minimize fragmented care and foster appropriate
utilization of services. This includes navigating transitions of
care generally from hospital or facility to home or community
facilities.
- Facilitates interdisciplinary communication among care team
members to include specialists, PCP, RN, psychiatrist and other key
providers. Interfaces with key providers across the care continuum
(e.g. discharge planners, social workers, physicians, psychiatrist,
etc.) within the hospital, primary care practices, public health
and social service departments, as well as behavioral health
agencies and other community resources to assure that patients are
linked to and engaged in services.
- Provides 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
consider ethnic and cultural backgrounds.
- Connects with patients and other care team members in a variety
of settings, to include patient homes, community agencies and other
locations, primary care practices, and telephone and other virtual
platforms. This position may require home visits based on business
rules and clinical need of identified patient population. -
- Follows established policies, procedures, and workflows.
- Participates in quality assurance/performance improvement
activities as requested.
- Provides feedback to Team Lead, management, and executive
leadership 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.
- Provide other related duties incidental to the work described
herein. -Required Qualifications at this LevelEducation: - - - - -
- - - - - - - - - - - - - - - - - - - - - -
- Bachelor's degree in Nursing or Master's degree that supports
licensure by the NC Board of Licensed Clinical Mental Health
Counselors (i.e., counseling, social work, allied/behavioral
health).Experience: - - - - - - - - - - - - - - - - - - - - - - - -
- - -
- 3 years of relevant clinical experience required. -Degrees,
Licensure, and/or Certification: - -
- Bachelor's degree in Nursing or Master's degree that supports
licensure by the NC Board of Licensed Clinical Mental Health
Counselors (i.e., counseling, social work, allied/behavioral
health).Degrees, Licensure, and/or Certification:
--- - - -Candidates with a BSN must have current or compact RN
licensure in the state of NC
--- - - -Candidates with a Master's degree (e.g., psychology,
social work, counseling, or related behavioral health program) must
have a current licensure by one of the following NC Boards:
Licensed Clinical Social Worker (LCSW), Licensed Clinical Addiction
Specialist (LCAS), or Licensed Clinical Mental Health Counselor
(LCMHC)
--- - - -All candidates/employees require a case management
certification (ACM, CCM, or ANCC) within 3 years of hire
-Knowledge, Skills, and Abilities:
- Exceptional verbal/written communication and facilitation
skills
- Self-driven and able to work effectively in a self-directed
role
- Excellent problem-solving skills
- Effectively able to manage multiple priorities in a fast-paced
and evolving environment
- Demonstrates basic computer skills to complete job functionsJob
Code: 00005495 POPULATION HEALTH CARE MANAGER
Job Level: G1 -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 communityfeel 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 essential job 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. -
Keywords: Duke Health, Durham , Population Health Care Manager, Healthcare , Durham, North Carolina
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