Complex Care Population Health Manager

Duke PA; Durham, Northern (NC, KY); Hybrid; USD 65,000 - 90,000; Full time

Job summary

Duke Connected Care in Durham, NC seeks a Population Health Care Manager to lead complex care management for patients with chronic conditions. You will perform disease management, care plan development, and referrals as part of an interdisciplinary team to improve outcomes and reduce hospitalizations.

Responsibilities include coordinating assessments, documenting activities, engaging patients and families, and ensuring seamless transitions of care across providers and settings.

Qualifications

• 3 years of clinical experience required.
• Bachelor's degree in a clinical field such as Nursing, Counseling, Social Work, Therapy, Allied Health, or community health related fields.
• Current license in at least one of these areas: NC RN, NC LCSW, NC LPC, NC LAS; ACM/CCM certification within 3 years of hire.

Responsibilities

• Coordinate and facilitate timely assessments, care plans, and interventions for identified patient population.
• Access and review data (medical records, claims, program metrics) to target outreach and intervention.
• Perform targeted interventions to connect patients with primary care and other health resources.
• Engage patients and families in decision-making and self-management.
• Document all activity electronically in Maestro and other systems.
• Coordinate with providers to minimize fragmented care and transitions from hospital to home.

Education

Bachelor's degree in a clinical field

RN licensure in North Carolina

Licensed Clinical Social Worker (NC)

Licensed Professional Counselor (NC)

Licensed Addiction Specialist (NC)

ACM or CCM certification within 3 years

Job description

Duke Connected Care in Durham, NC seeks a Population Health Care Manager to lead complex care management for patients with chronic conditions. You will perform disease management, care plan development, and referrals as part of an interdisciplinary team to improve outcomes and reduce hospitalizations.

Responsibilities include coordinating assessments, documenting activities, engaging patients and families, and ensuring seamless transitions of care across providers and settings.