Population Health Manager: Care Coordination & Outcomes

Duke PA; Durham, Northern (NC, KY); Hybrid; USD 95,000 - 120,000; Full time

Job summary

Duke Connected Care is seeking a Population Health Care Manager (PHCM) for the QuEST initiative in Durham, NC. This role provides clinical leadership to manage designated patient populations across the care continuum, focusing on chronic disease management, preventive care, hospital follow-up, and care coordination within an interdisciplinary team.

Under the QuEST Manager's direction, you will support quality initiatives, education, performance improvement, and data-driven care.

Qualifications

• BSN required or Master’s degree in Counseling/Social Work/Psychology/Behavioral Health with licensure eligibility.
• Minimum of three (3) years of relevant clinical experience.
• RN licensure in North Carolina or a compact state for nursing candidates; NC licensure or equivalent for behavioral health candidates.

Responsibilities

• Manage a designated caseload and coordinate assessments, care plans, interventions, and follow-up activities.
• Conduct comprehensive evaluations of health status, social determinants, behavioral health needs, and environmental factors.
• Develop and implement individualized, patient-centered care plans to address barriers and health concerns.
• Support chronic disease management and disease prevention initiatives.
• Coordinate transitions of care and discharge planning across settings.
• Maintain accurate documentation within Maestro and other systems; monitor outcomes and performance metrics.

Skills

Care management

Care coordination

Interdisciplinary collaboration

Patient education

Quality improvement

Documentation

Communication

Education

BSN and NC RN licensure

Master’s degree in Counseling / Social Work / Psychology / Behavioral Health

Tools

Maestro EMR

Job description

Duke Connected Care is seeking a Population Health Care Manager (PHCM) for the QuEST initiative in Durham, NC. This role provides clinical leadership to manage designated patient populations across the care continuum, focusing on chronic disease management, preventive care, hospital follow-up, and care coordination within an interdisciplinary team.

Under the QuEST Manager's direction, you will support quality initiatives, education, performance improvement, and data-driven care.