Population Health Resource Associate- AMH+/Hybrid Part-Time

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Occ Summary

The Population Health Resource Associate will implement, plan andcoordinate comprehensive patient plans to ensure that patients receiveappropriate overall medical care, therapy and training services, in aneffort to enable theirrecovery or management of complex, chronic healthconditions. This work is done in conjunction with the Co mplex Care Team(s).

Work Performed

Provide outreach a ndcare management support to patients; educateclients of available commu nity resources. Assist clients withcoordination of care between healthca reproviders and other complex careteam(s).Performs a range of non-clinic al care management functions (outreach,health education, informal counse ling, social support, resourcelinkages, interpretation/ translation, tra nsportation coordination, andadvocacy) for an active patient caseload to build individual andcommunity capacity by increasing health knowledge an d self-sufficiencyand accurately documents activities with follow-up and plans of action.Act as a client advocate and support the development ofp roblem solvingskills; provide instructions in basic health care procedur es.Coordinate and/or participate in community health activities to inclu depreparing patient education materials,brochures, bulletins, newslette rsand other promotional materials and/or publications. Attend off-site, outreach education and recruitment sessions.Maintain liaison with other programs, offices and departments at Duke tocoordinate program business and to accomplish program objectives.Interface with external organizatio ns as appropriate to ensurecooperative efforts are enhanced and availabl e resources are utilized.Promote program on key coalitions and task forc es to fostercollaboration, educate constituencies, leverage resources,an d reduceduplication of services.Monitor and evaluate program effectivene ss, investigate trends, andrecommend and implement modifications to impr ove program effectiveness.Prepare reports and conduct preliminary analys es setting forth progressand adverse trends.Perform other related dutt a cuity levelscan create a stressfulatmosphere.Additional responsibiliies incidental to the work described herein.The work activity and patienties could include:-- Make home visits and other contacts with clients,as ne cessary.Coordinates regular practice visits and attends provider meeting s topromote coordination of patient care.-- Accompany clients to schedul ed appointments and/or referral sites, asneeded.-- Serves as liaison to health/social services providers to build andmaintain effective relation ships with physicians, site leadership,hospital staff and other communit y stakeholders to ensure timely andappropriate patient follow-up.Team Le ad Responsibilities:-- Provides regularoversight (including accompanime nt into the field)of new hires and completes required performance adhere nce to programstandards and implements improvement and developmentplans as needed.-- Utilize leadership principles to mobilize team to achieve p ositiveoutcomes.-- Conduct follow-up on outstanding matters to insure th ey aresuccessfully resolved.-- Represents program interests at internal and external meetings.-- Collect and analyze key statistics (disease reg istries, biometrics,care management productivity, etc.) to ensureadheren ce to establishedcare management protocols and benchmarks and investigat es methods forimproving service delivery.-- Complete chart reviews and f acilitate peer review process amongassigned staff members.-- Utilizes da ta to implement individual and program-level performanceimprovement acti vities (standardization of care, establishment ofdisease and population health metrics, consistency of reporting,information flow and management , job functions).-- Assess training needs of new and existing staff, ide ntifies andcoordinates continuing education, in-services and staff devel opmentopportunities to ensure that skill-sets adhere to established core competencies.

Knowledge, Skills and Abilities

The wor k activity and patient acuity levels can create a stressfulatmosphere, t herefore individuals successful in this job are:-- Organized andmotivate d by a fast-paced environment-- Able to manage multiple tasks/projects s imultaneously-- Proficient in review and assess needs quickly--Strong wi th the use of computer software tools and data files-- Comfortable with continuous change and self-initiating-- Able to complete documentation i n a quick and efficient manner (willbe in legal medical recordand other software systems developed for caremanagement and population based progr am metrics)

Level Characteristics

Additional job expe ctations i