Population Health Care Manager- AMH+

At Duke Health , we're driven by a commitment to compassionate care that changes the lives of patients, their loved ones, and the greater community. No matter where your talents lie, join us and discover how we can advance health together.

Pediatric Experience Highly Preferred( BSN / LCSW / LPC or LCMHC)

Job Summary

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 (, 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

Required Qualifications at this Level

Education :                           Â

Bachelor's degree in Nursing or Master's degree that supports licensure by the NC Board of Licensed Clinical Mental Health Counselors (, counseling, social work, allied / behavioral health).

Experience :                           Â

3 years of relevant clinical experience required.

Degrees, Licensure, and / or Certification :  Â

BSN required and must have current or compact RN licensure in state of NC

OR

Master's degree (, psychology, social work, counseling, or related behavioral health program) and

Current licensure Requirement : by one of the following NC Boards :

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