Population Health Resource Associate- Embedded at Duke Family Medicine

Job Summary

The Population Health Resource Associate will implement, plan and coordinate comprehensive patient plans to ensure 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 and care management support to patients; educate clients of available community resources.
• Aid clients with coordination of care between healthcare providers and other complex care team(s).
• Perform a range of non-clinical care management functions (outreach, health education, informal counseling, social support, resource linkages, interpretation/translation, transportation coordination, and advocacy) for an active patient caseload to build individual and community capacity by increasing health knowledge and self-sufficiency.
• Act as a client advocate and support the development of problem-solving skills; provide instructions in basic health care procedures.
• Cook up and participate in community health activities to include preparing patient education materials, brochures, bulletins, newsletters and other promotional materials and/or publications.
• Attend off-site, outreach education and recruitment sessions.
• Maintain liaison with other programs, offices and departments at Duke to coordinate program business and to accomplish program objectives.
• Interface with external organizations as appropriate to ensure cooperative efforts are enhanced and available resources are utilized.
• Promote program on key coalitions and task forces to foster collaboration, educate constituencies, leverage resources, and reduce duplication of services.
• Monitor and evaluate program effectiveness, investigate trends, and recommend and implement modifications to improve program effectiveness.
• Prepare reports and conduct preliminary analyses setting forth progress and adverse trends.

Knowledge, Skills and Abilities

• 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

• 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.