Population Health Care Manager- Resource Center Team Lead

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 eligible for a $7,500.00 Commitment Bonus paid over 1 year

 

Personnel Area:  DIN/Connected Care

 

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.

 

Resource Center: The Resource Center is a team within the Population Health Management Office (PHMO) that focuses on patient care transitions, supporting inpatient case management with discharge planning and completes post-discharge follow up phone calls to patients, assisting them with key components that contribute to improved outcomes post-discharge. 

 

Location

Durham, North Carolina Remote – primarily telephonic, work from home with occasional in-office

 

Hours:

Monday-Friday, occasional Saturday and holiday hours.

 

General Description 

The Resource Center Population Health Care Manager Team Lead works in collaboration with the PHMO and Duke inpatient case management leadership to ensure that the work of the Resource Center is accomplished effectively and supportive of patient care transitions. The Team Lead is responsible for day-to-day supervision of assigned team and in collaboration with leadership, identifies, plans and executes activities to promote effective transitional care management and ensure compliance according to policies and procedures. 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.

Work Performed

Responsible for understanding the day-to-day work of the team in order to assist team members in any job function, inform processes and programs internal and external to PHMO, and serve as a preceptor for new team members.

• Participates in the hiring process for new team members per PHMO policy and procedure.
• Supports team members in their work through regularly scheduled one-on-one and team meetings.
• Models Duke values.
• Works closely with Resource Center leadership and team members to develop, implement, and re-evaluate work flows to ensure they are up-to-date and address best practice.
• Monitors team outcomes to include:
  • Timely completion of post-discharge phone calls (i.e., transitional care calls) to patients, complete and accurate documentation and communication to pertinent care team members