Population Health Manager: Care Coordination & Outcomes

Duke University Health System; Durham (NC); On-site; USD 85,000 - 110,000; Full time

Job summary

Duke Connected Care is seeking a Population Health Care Manager (PHCM) for the QuEST program in Durham. The PHCM will lead care coordination, manage a designated caseload, and work with clinicians to improve outcomes and access to services across clinics, homes, and community settings.

Responsibilities include care planning, transitions of care, medication education, and engagement with patients and families to promote self-management and address social determinants of health.

Qualifications

• BSN, or a master's degree in Counseling, Social Work, Psychology, Behavioral Health, or related field.
• Minimum of three years of relevant clinical experience.
• Certification in Case Management within three years of hire (ACM, CCM, or ANCC).

Responsibilities

• Care management: coordinate assessments, care plans, interventions and follow-ups.
• Conduct comprehensive evaluations of health, social determinants, behavioral health needs.
• Develop and implement patient-centered care plans addressing barriers.
• Coordinate transitions of care and discharge planning.
• Perform medication reconciliation and patient education.
• Facilitate preventive care and quality gap closure initiatives.
• Engage patients and families in care planning and decision-making.
• Collaborate with physicians, nurses, social workers and community partners.
• Provide outreach in person, by phone, and virtually; connect to community resources.
• Maintain documentation and monitor outcomes in Maestro and other systems.

Education

BSN or relevant master's degree

Job description

Duke Connected Care is seeking a Population Health Care Manager (PHCM) for the QuEST program in Durham. The PHCM will lead care coordination, manage a designated caseload, and work with clinicians to improve outcomes and access to services across clinics, homes, and community settings.

Responsibilities include care planning, transitions of care, medication education, and engagement with patients and families to promote self-management and address social determinants of health.