Population Health Care Manager- QuEST Team

Population Health Care Manager

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.

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, medical, behavioral health, and psychosocial needs by performing care management and care coordination functions working within the Education and Quality Team.

Preferred experience for this specialized role is Quality Assurance, Auditing, Regulatory Compliance, and Training and Education. 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 complete timely development, completion, and 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 individualized treatment plans 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.

Required Qualifications at this Level

Education :

Experience :

Degrees, Licensure, and / or Certification :

Knowledge, Skills, and Abilities :

Distinguishing Characteristics of this Level

The intent of this job description is to provide a representative and level of the types of duties and responsibilities that will be required of positions given this title and shall not be construed as a declaration of the total of the specific duties and responsibilities of any particular position. Employees may be directed to perform job-related tasks other than those specifically presented in this description.

Duke University is an Affirmative Action / Equal Opportunity Employer committed to providing employment opportunity without regard to an individual's age, color, disability, gender, gender expression, gender identity, genetic information, national origin, race, religion, sex, sexual orientation, or veteran status.

Duke aspires to create a community built on collaboration, innovation, creativity, and belonging. Our collective success depends on the robust exchange of ideasan exchange that is best when the rich diversity of our perspectives, backgrounds, and experiences flourishes. To achieve this exchange, it is essential that all members of the community feel secure and welcome, that the contributions of all individuals are respected, and that all voices are heard. All members of our community have a responsibility to uphold these values.

Essential Physical Job Functions

Certain jobs at Duke University and Duke University Health System may include essential job functions that require specific physical and / or mental abilities. Additional information and provision for requests for reasonable accommodation will be provided by each hiring department.

POPULATION HEALTH CARE MANAGER Job Level : G2