The Population Health Care Manager is responsible for clinical expertise for specific complex and/or rising risk patient populations with a design to meet specific contractual and program related requirements. This role will perform disease management, assessment of disease, care plan development and facilitation, referral to appropriate levels of care, etc. 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

• Coordinate and facilitate timely implementation of assessments, care plans, and appropriate interventions for identified patient population to determine patient health, social situation, physical environment, mental health, substance use, expressed trauma, economic status, and education to patients while exercising discretion and independent judgment; following established policies and procedures.
• Provide 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.
• Perform targeted interventions to assist patients with connection to primary care providers and other health care resources. Involve the patient and their support systems (i.e. caregiver, family, etc.) in the decision-making process.
• Use a patient-centric, collaborative partnership approach to assist the patient with improved self-management and identifying barriers by addressing the total individual, inclusive of medical, psychosocial, behavioral, and spiritual needs.
• Utilize proven processes to measure a patients understanding and acceptance of the proposed plan(s), his/her willingness to change, and his/her support to maintain health behavior change.
• Apply teaching and learning theories to assist patients and families with physical and emotional impact of body changes and chronic illness.
• Monitor quality and effectiveness of interventions to the population by setting long term and/or short-term specific, measurable goal(s).
• Electronically document all activity in Maestro, and other documentation systems relevant t o the position.
• Communicate and coordinate with all provider(s) and member(s) of the care team as needed to minimize fragmented care and foster appropriate utilization of services. This will include, navigating transitions of care generally from hospital to home or community facilities.
• Facilitate interdisciplinary communication to include specialists, PCP, RN, psychiatrist and other key providers.
• Interface with key providers (e.g. discharge planners, social workers, physicians, psychiatrist etc.) within the hospital, primary care practices, public health and social service departments, as well as mental health agencies and other community resources to assure that patients are linked to and engaged in services.
• Provide 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 services provided are sensitive to the needs of individual patients and take into account ethnic and cultural backgrounds.
• This position may require home visits based on business rules and clinical need of identified patient population.
• Provide feedback to TL, management, and executive leadership that will enhance negotiations with payers, improve care management, and/or address gaps in care.
• Develop and maintain positive relationships with customers internal and external to Duke Health System.

Minimum Qualifications

Education

Bachelor's degree in a clinical field such as Nursing, Counseling, Social Work, Therapy, Allied Health, or community health related fields.

Experience

3 years of clinical experience required.

Degrees, Licensures, Certifications

Must have a current license in at least one of these areas:

Current or compact RN licensure in the state of North Carolina

Current licensure as a licensed clinical social worker by the NC Social Work Certification and Licensure Board

Current licensure as a Licensed Professional Counselor by the state of NC,

Current licensure as a Licensed Addiction Specialist by the state of North Carolina.

Requires ACM or CCM certification within 3 years of hire date.