Population Health Care Manager Complex Care Management

Duke Connected Care is a community-based, physician-led network of doctors, hospitals, and other healthcare providers working together to deliver high-quality care to Medicare Fee-for-Service patients in Durham and surrounding areas.

About the role

The Population Health Care Manager provides clinical expertise for specific complex and/or rising-risk patient populations to meet contractual and program-related requirements. This role performs disease management, assessment, care plan development, and facilitation, ensuring excellence in transitions of care to achieve optimal clinical outcomes. The focus is on improving health status and care for individuals with chronic conditions, complex medical needs, mental health issues, and psychosocial challenges.

Responsibilities

• Coordinate and facilitate timely implementation of assessments, care plans, and interventions for identified patient populations, evaluating health, social situation, physical environment, mental health, substance use, trauma, economic status, and education.
• Provide individual treatment to address barriers using systematically identified data from patient records, claims, and program metrics to target outreach, education, and intervention.
• Perform targeted interventions to connect patients with primary care providers and other healthcare resources, involving patients and their support systems in decision-making.
• Use a patient-centric, collaborative approach to assist patients with self-management and barrier identification, addressing medical, psychosocial, behavioral, and spiritual needs.
• Apply teaching and learning theories to help patients and families manage the physical and emotional impacts of chronic illness.
• Monitor the quality and effectiveness of interventions by setting specific, measurable long-term and short-term goals.
• Electronically document all activity in Maestro and other relevant systems.
• Communicate and coordinate with providers and care team members to minimize fragmented care and foster appropriate service utilization, including navigating transitions of care (e.g., hospital to home).
• Facilitate interdisciplinary communication among specialists, primary care providers, nurses, psychiatrists, and other key providers.
• Interface with discharge planners, social workers, physicians, psychiatrists, public health departments, social service agencies, and mental health organizations to link patients to services.
• Conduct on-site, community, and telephonic outreach to patients, providers, and community stakeholders, considering ethnic and cultural backgrounds.
• Perform home visits as needed based on clinical requirements.
• Provide feedback to leadership to enhance payer negotiations, improve care management, and address gaps in care.
• Develop and maintain positive relationships with internal and external customers.

Requirements

• Bachelor’s degree in a clinical field such as Nursing, Counseling, Social Work, Therapy, Allied Health, or a community health-related field.
• 3 years of clinical experience.
• Current license in one of the following:
  • RN licensure (current or compact) in North Carolina.
  • Licensed Clinical Social Worker (LCSW) by the NC Social Work Certification and Licensure Board.
  • Licensed Professional Counselor (LPC) in North Carolina.
  • Licensed Addiction Specialist in North Carolina.
• ACM or CCM certification required within 3 years of hire.