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Population Health Care Manager-QuEST Team

  • Job
    Full-time
    Mid Level
  • Healthcare
  • Durham
    Remote

AI generated summary

  • You need a bachelor's in a clinical field (BSN preferred), 3 years of experience, NC RN licensure or relevant master's with specific licenses, and case management certification within 3 years.
  • You will coordinate patient assessments, develop care plans, facilitate interventions, engage patients in decision-making, document activities, and collaborate with care teams to ensure effective service delivery.

Requirements

  • Bachelor's degree in a clinical field such as Nursing, Counseling, Social Work, Therapy, Allied Health, or community health related fields. BSN highly preferred
  • 3 years of relevant clinical experience required.
  • Candidates with a BSN must have current or compact RN licensure in state of NC
  • Candidates with a Master's degree (e.g., psychology, social work, counseling, or related behavioral health program) must have a current licensure by one of the following NC Boards: Licensed Clinical Social Worker (LCSW), Licensed Clinical Addiction Specialist (LCAS), or Licensed Clinical Mental Health Counselor (LCMHC)
  • All candidate/employees require a case management certification (ACM, CCM, or ANCC) within 3 years of hire.

Responsibilities

  • 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.
  • Electronically document all activity in Maestro, and other documentation systems relevant to 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 as well as home to community facilities.
  • Facilitate interdisciplinary communication to include specialists, PCP, RN, psychiatrist and other key providers. Interface with key providers (e.g. discharge planners, case managers, 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.
  • 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.

FAQs

What is the primary focus of the Population Health Care Manager role?

The primary focus of the Population Health Care Manager is to provide clinical expertise and support for care transitions of patients being discharged from the Duke University Health System and other identified hospitals, with an emphasis on improving the health status and care of individuals with chronic conditions and complex issues.

What qualifications are required for this position?

A Bachelor's degree in a clinical field such as Nursing, Counseling, Social Work, Therapy, Allied Health, or community health-related fields is required, with a BSN being highly preferred. Additionally, candidates must have relevant clinical experience and appropriate licensure or certifications.

What type of experience is necessary for applicants?

Applicants are required to have 3 years of relevant clinical experience in a related field.

Is licensure required for this role?

Yes, candidates with a BSN must have current or compact RN licensure in the state of NC, while those with a Master's degree in certain fields must have licensure from the appropriate NC Boards.

Are there any required certifications for this position?

Yes, all candidates/employees are required to obtain a case management certification (such as ACM, CCM, or ANCC) within 3 years of hire.

Will the Population Health Care Manager work independently?

While the role requires independent judgment and discretion, the manager will function as part of an interdisciplinary team, coordinating care and ensuring seamless transitions.

Does this position involve communication with external providers and community stakeholders?

Yes, the role includes facilitating communication and coordination with providers and community stakeholders to assist patients and link them to the appropriate services.

What kind of patient outreach is expected in this role?

The Population Health Care Manager will provide on-site, community, and telephonic outreach to patients, which includes identifying treatment history and patient care components.

Will the Population Health Care Manager be involved in care plan development?

Yes, the manager is responsible for coordinating and facilitating the implementation of assessments and care plans for the identified patient population.

What is the work environment like for this position?

The work environment includes a mix of telephonic outreach, community engagement, and interaction with patients and providers, with an emphasis on teamwork within a health care setting.

Is this position full-time or part-time?

The job description does not specify; interested applicants should inquire during the application process for specifics regarding hours and scheduling.

Does Duke Connected Care offer opportunities for professional development?

The job description implies a commitment to professional growth by requiring ongoing certification, suggesting they value continued education and development.

What is Duke's stance on diversity and inclusion?

Duke is committed to creating a diverse community and ensuring that all voices are heard, with a focus on collaboration, innovation, and belonging.

Fueled by creativity, informed by scholarship

Education
Industry
1-10
Employees
1924
Founded Year

Mission & Purpose

Duke University is a leading academic institution dedicated to excellence in education, research, and community service. Their ultimate mission is to advance knowledge and develop leaders who can make a positive impact on society. Duke University aims to provide a transformative educational experience, fostering intellectual growth, critical thinking, and ethical leadership. By integrating rigorous academics with a commitment to social responsibility, Duke seeks to contribute to the global community and address pressing challenges through innovation and collaboration.

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