Population Health Care Manager-Embedded at Duke Outpatient Clinic (BSN Highly Preferred)

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.

 

External Candidates are eligible for a $10,000.00 Commitment Bonus paid over 2 years

Home Visits are required for this position

General Description of the Job Class

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 adherence

Duties 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