Population Health Care Manager Care Transition PRN

Duke Careers; Durham (NC); Remoto; USD 70.000 - 95.000; Tempo pieno

Descrizione del lavoro

Duke Connected Care is seeking a Population Health Care Manager for the Care Transitions Team. This PRN/Remote role focuses on coordinating assessments, care plans, and interventions for discharged patients, with an emphasis on chronic conditions and psychosocial factors.

You will support inpatient case management, follow-up calls, and continuity of care across hospital-to-home transitions, working within an interdisciplinary team to improve clinical outcomes.

Competenze

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

Mansioni

• Coordinate assessments, care plans, and interventions for identified patient population across health, social, physical, mental health, and education factors.
• Provide individualized treatment addressing barriers by accessing data from patient records, claims, and program metrics.
• Involve patients and support systems in decision-making to improve self-management and access to primary care.
• Use teaching/learning theories to support patients with chronic illness.
• Electronically document all activity in Maestro and other systems.
• Communicate with care teams to minimize fragmented care and coordinate transitions hospital-to-home or community facilities.
• Facilitate interdisciplinary communication with specialists, PCPs, nurses, psychiatrists, and other providers.
• Provide on-site, community, and telephonic outreach to identify treatment history and ensure culturally sensitive care.
• Provide feedback to leadership to improve care, payer negotiations, and identify gaps in care.
• Develop and maintain positive relationships with internal and external stakeholders.

Formazione

Bachelor's degree in clinical field

Descrizione del lavoro

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Population Health Care Manager Care Transition PRN

Work Arrangement: Remote

Regular or Temporary: Regular

Location: Durham, NC, US, 27710

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 itssurrounding areas.

General Description of the Job Class

The Population Health Care Manager for the Care Transitions Team is responsible for providing clinical expertise, support, and guidance for care transitions of patients being discharged from the Duke University Health System as well as other identified hospitals and facilities. This role consists of two primary functions:

• Support for inpatient case management with core administrative functions related to discharge disposition prior to discharge (e.g., FL2s, referrals to SNFs and other facilities, etc.)
• Support for patients telephonically once they have been discharged through proactive transitional care phone calls as well as receiving phone calls from patients needing assistance post-discharge. The Care Transitions Population Health Care Manager will perform disease and symptom management, assessment of disease, care plan development and facilitation, and 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. This role has a focus on improving the health status and care for individuals with chronic conditions with complex medical, mental health and psychosocial issues.

Duties and Responsibilities of this Level

• 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.

Required Qualifications at this Level

Education

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

Experience

3years of clinical experience required

Degrees, Licensure, and/or Certification

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, or current licensure as a Licensed Addiction Specialist by the state of North Carolina. Requires ACM or CCM certification within 3 years of hire date.

Duke is an 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 (including pregnancy and pregnancy related conditions), sexual orientation or military status.

Duke aspires to create a community built on collaboration, innovation, creativity, and belonging. Our collective success depends on the robust exchange of ideas- an 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.

Duke aspires to create a community built on collaboration, innovation, creativity, and belonging. Our collective success depends on the robust exchange of ideas- an 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.

Nearest Major Market: Durham

Nearest Secondary Market: Raleigh

Read more about Duke's commitment to affirmative action and nondiscrimination at hr.duke.edu/eeo.