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.

Case and Care Management highly preferred for this position

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.