Population Health Resource Associate

Duke University; Durham (NC); On-site; USD 42,000 - 60,000; Full time

Job summary

Duke Connected Care, a community-based, physician-led network in Durham, seeks a Population Health Resource Associate to plan and coordinate comprehensive patient plans for individuals with complex health needs, in collaboration with the Complex Care Team. The role focuses on ensuring patients receive appropriate medical care, therapy, and training services to support their recovery or ongoing management.

You will perform outreach, care management, and education, connect patients with community

Qualifications

• High school diploma or equivalent with strong communications and organizational skills.
• Two years of customer service experience, especially via phone or public contact.
• Experience with electronic medical records software preferred.
• Associate's degree or higher may substitute for experience.

Responsibilities

• Provide outreach, care management support, and health education to patients and families.
• Coordinate care between patients and healthcare providers to ensure continuity of services.
• Maintain accurate documentation of patient interactions and outcomes.
• Lead data-driven performance improvement initiatives in care coordination.
• Represent the program at meetings and community events.

Skills

Organized

Multitasking

Data analysis

Strong communication

Education

High school diploma

Associate degree or higher

Tools

EMR software

Job description

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 its surrounding areas.

Job Summary

The Population Health Resource Associate will implement, plan and coordinate comprehensive patient plans to ensure that patients receive appropriate overall medical care, therapy and training services, in an effort to enable their recovery or management of complex, chronic health conditions. This work is done in conjunction with the Complex Care Team(s).

Work Performed

• Provide outreach, care management support, and health education to patients and families, connecting them with appropriate community resources.
• Coordinate care between patients, healthcare providers, and interdisciplinary care teams to ensure continuity of services.
• Perform non-clinical care management activities including:
• Patient outreach and engagement
• Health education and informal counseling
• Social support and advocacy
• Resource linkage and referrals
• Interpretation/translation services
• Transportation coordination
• Maintain accurate documentation of patient interactions, follow-up activities, care plans, and outcomes.
• Serve as a patient advocate by supporting problem-solving, self-sufficiency, and health literacy development.
• Provide instruction on basic healthcare procedures and self-management strategies.
• Develop and distribute patient education materials, brochures, newsletters, bulletins, and other health promotion resources.
• Coordinate and participate in community health initiatives, outreach events, recruitment activities, and educational programs.
• Attend off-site outreach, education, and recruitment sessions to expand community engagement.
• Collaborate with Duke Health departments, programs, and external community organizations to achieve program objectives and maximize resource utilization.
• Build and maintain partnerships with community stakeholders, coalitions, task forces, and service providers to improve access to care and reduce service duplication.
• Monitor program effectiveness, analyze trends, and recommend process improvements to enhance service delivery and patient outcomes.
• Prepare reports, track program metrics, and conduct preliminary analyses on progress, outcomes, and emerging needs.
• Conduct home visits and community-based client contacts as necessary to support patient care needs.
• Coordinate practice visits and participate in provider meetings to improve care coordination and communication.
• Accompany patients to medical appointments and referral visits when needed.
• Serve as a liaison between patients and healthcare/social service providers to ensure timely follow-up and access to services.
• Perform additional duties as assigned in support of departmental and organizational goals.
• Provide day-to-day oversight, mentorship, and field-based coaching for new and existing staff.
• Monitor staff compliance with program standards and develop performance improvement plans as needed.
• Utilize leadership principles to motivate teams and drive positive patient and program outcomes.
• Track and follow up on outstanding issues to ensure timely resolution.
• Represent the program at internal and external meetings, committees, and community events.
• Collect, analyze, and report key performance metrics, including disease registries, biometrics, care management productivity, and quality benchmarks.
• Review patient charts and facilitate peer review activities to ensure quality and consistency of care management services.
• Lead data-driven performance improvement initiatives focused on care standardization, population health outcomes, reporting accuracy, workflow efficiency, and information management.
• Assess training and development needs for staff and coordinate continuing education, in-service training, and professional development opportunities.
• Ensure team competencies align with established program standards, best practices, and organizational goals.

Knowledge, Skills And Abilities

The work activity and patient acuity levels can create a stressful atmosphere, therefore individuals successful in this job are: Organized and motivated by a fast-paced environment. Able to manage multiple tasks/projects simultaneously. Proficient in review and assess needs quickly. Strong with the use of computer software tools and data files. Comfortable with continuous change and self-initiating. Able to complete documentation in a quick and efficient manner (will be in legal medical record and other software systems developed for care management and population based program metrics).

Level Characteristics

Additional job expectations include the ability to: Maintain strict confidentiality. Promote programs and services to community. Build effective and trusting relationships with patient/peers. Use motivational interviewing and active-listening skills when assessing patient conditions, problems and interests. Use conflict-resolution skills when reaching consensus about plans of care and treatment decisions. Demonstrate confidence, compassion, political savvy, as well as attention to detail to apply these skills as decisions dictate. Use data to analyze trends and to verify data.

Minimum Qualifications

Education High school degree or equivalent, as well as strong communications and organizational skills.

Experience

Work generally requires customer service experience through patient or public contact. Two years of experience with customer interactions via phone and marketing/communications preferred. Active user of electronic medical records software strongly preferred. An associate's degree or higher may be substituted for experience.

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.