Population Health Care Manager Position Available In Durham, North Carolina

Job Description:

Duke Connected Care, a community-based, physician-led network,includes a group of doctors, hospitals and other healthcareproviders who work together to deliver high-quality care toMedicare Fee-for-Service patients in Durham and itssurroundingareas.•Home Visits are required for this positionExternalCandidates are eligible for a $10,000.00 Commitment Bonus paid over2 yearsEmbedded at a Duke Outpatient Clinic•General Description-The Population Health Care Manager is responsible for deliveringclinical expertise to manage health care needs of specific patientpopulations across the continuum of care with a goal of improvingpatient health outcomes and reducing unnecessary utilization andcost. This role functions as an integral part of aninterdisciplinary team and a patient’s care team to optimizeclinical outcomes through a seamless model of transitions, access,and care. This role focuses on improving the health status andconnection to resources, preventive care, hospital follow-up, andongoing healthcare for individuals with chronic health conditionsas well as addressing frequent hospital and emergency departmentutilization, and medical, behavioral health, and psychosocial needsby performing care management and care coordination functions in avariety of settings that include a patient’s home, community, andclinic.

These functions include:

Disease management and chronic disease support Timely completion of clinical assessment and patient-centeredcare plan development, facilitation, and implementation Transitional Care Management/care transition support inclusiveof 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 forhealth, social, and behavioral needs Patient activation and coordination for quality and preventivecare gap closure Assistance with and completion of medication reconciliation,access, education, and adherenceDuties and Responsibilities of thisLevel Manages a designated caseload to coordinate and facilitatetimely implementation of assessments, care plans, and appropriateinterventions for identified patient population to determinepatient health, social situation, physical environment, behavioralhealth, substance use, expressed trauma, economic status, andeducation to patients while exercising discretion and independentjudgment. Provides individual treatment to address barriers andidentified concerns by accessing systematically identified datafrom multiple sources such as patient medical records, claims, andprogram metric reports to target recipient(s) and provider(s) foroutreach, education, and intervention. Performs targetedinterventions to assist patients with connection to primary careproviders and other health care resources. Involves the patient and their support systems (i.e. caregiver,family, etc.) in the decision-making process. Uses apatient-centric, collaborative partnership approach to assist thepatient with improved self-management and identifying barriersthrough a “whole-person” approach, inclusive of medical,psychosocial, behavioral, and spiritual needs. Utilizes proven processes to measure a patient’s understandingand acceptance of the proposed plan(s), his/her willingness tochange, and his/her support to maintain health behaviorchange. Applies teaching and learning theories to assist patients andfamilies with physical and emotional impact of body changes andchronic illness. Monitors quality and effectiveness of interventions to thepopulation by setting long term and/or short-term specific,measurable goal(s). Maintains timely documentation of all care management activityin Maestro, and other documentation systems relevant to theposition. Effectively communicates and coordinates with appropriate careteam members to minimize fragmented care and foster appropriateutilization of services. This includes navigating transitions ofcare generally from hospital or facility to home or communityfacilities. Facilitates interdisciplinary communication among care teammembers to include specialists, PCP, RN, psychiatrist and other keyproviders. Interfaces with key providers across the care continuum(e.g. discharge planners, social workers, physicians, psychiatrist,etc.) within the hospital, primary care practices, public healthand social service departments, as well as behavioral healthagencies and other community resources to assure that patients arelinked to and engaged in services. Provides on-site, community, and telephonic outreach topatients, providers, and community stakeholders assisting withidentification of treatment history, diagnoses and patient carecomponents both internally and externally to ensure that servicesprovided are sensitive to the needs of individual patients andconsider ethnic and cultural backgrounds. Connects with patients and other care team members in a varietyof settings, to include patient homes, community agencies and otherlocations, primary care practices, and telephone and other virtualplatforms. This position may require home visits based on businessrules and clinical need of identified patient population.•Follows established policies, procedures, and workflows. Participates in quality assurance/performance improvementactivities as requested. Provides feedback to Team Lead, management, and executiveleadership that will enhance negotiations with payers, improve caremanagement, and/or address gaps in care. Develop and maintain positive relationships with customersinternal and external to Duke Health System. Provide other related duties incidental to the work describedherein.•Required Qualifications at this

LevelEducation:

•Bachelor’s degree in Nursing or Master’s degree that supportslicensure by the NC Board of Licensed Clinical Mental HealthCounselors (i.e., counseling, social work, allied/behavioralhealth).

Experience:

•3 years of relevant clinical experience required.•Degrees,Licensure, and/or

Certification:

•Bachelor’s degree in Nursing or Master’s degree that supportslicensure by the NC Board of Licensed Clinical Mental HealthCounselors (i.e., counseling, social work, allied/behavioralhealth).Degrees, Licensure, and/or

Certification:

•-Candidates with a BSN must have current or compact RNlicensure in the state of NC•-Candidates with a Master’s degree (e.g., psychology,social work, counseling, or related behavioral health program) musthave a current licensure by one of the following

NC Boards:

Licensed Clinical Social Worker (LCSW), Licensed Clinical AddictionSpecialist (LCAS), or Licensed Clinical Mental Health Counselor(LCMHC)•-All candidates/employees require a case managementcertification (ACM, CCM, or ANCC) within 3 years of hire•

Knowledge, Skills, and Abilities:

Exceptional verbal/written communication and facilitationskills Self-driven and able to work effectively in a self-directedrole Excellent problem-solving skills Effectively able to manage multiple priorities in a fast-pacedand evolving environment Demonstrates basic computer skills to complete job functions

JobCode:

00005495 POPULATION

HEALTH CARE MANAGER

Job Level:

G1•Duke is an Affirmative Action/Equal OpportunityEmployer committed to providing employment opportunity withoutregard to an individual’s age, color, disability, gender, genderexpression, gender identity, genetic information, national origin,race, religion, sex, sexual orientation, or veteran status.•Dukeaspires to create a community built on collaboration, innovation,creativity, and belonging. Our collective success depends on therobust exchange of ideas-an exchange that is best when the richdiversity of our perspectives, backgrounds, and experiencesflourishes. To achieve this exchange, it is essential that allmembers of the communityfeel secure and welcome, that thecontributions of all individuals are respected, and that all voicesare heard. All members of our community have a responsibility touphold these values.•

Essential Physical Job Functions:

Certainjobs at Duke University and Duke University Health System mayinclude essential job functions that require specific physicaland/or mental abilities. Additional information and provision forrequests for reasonable accommodation will be provided by eachhiring department.•