Population Health Resource Associate- HUB

About the Role

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. The Population Health Resource Associate will implement, plan, and coordinate comprehensive patient plans to ensure patients receive appropriate medical care, therapy, and training services. This role supports recovery or management of complex, chronic health conditions in collaboration with the Complex Care Team(s).

Responsibilities

• Provide outreach and care management support to patients; educate clients about available community resources.
• Assist clients with coordination of care between healthcare providers and other complex care team(s).
• Perform non-clinical care management functions, including outreach, health education, informal counseling, social support, resource linkages, interpretation/translation, transportation coordination, and advocacy for an active patient caseload.
• Accurately document activities, follow-ups, and plans of action 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.
• Coordinate and/or participate in community health activities, including preparing patient education materials, brochures, bulletins, newsletters, and other promotional publications.
• Attend off-site outreach education and recruitment sessions.
• Maintain liaison with other programs, offices, and departments at Duke to coordinate program business and accomplish objectives.
• Interface with external organizations to enhance cooperative efforts and utilize available resources.
• Promote the 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 modifications to improve program outcomes.
• Prepare reports and conduct preliminary analyses of progress and adverse trends.
• Make home visits and other client contacts as necessary.
• Coordinate regular practice visits and attend provider meetings to promote coordination of patient care.
• Accompany clients to scheduled appointments and/or referral sites as needed.
• Serve as a liaison to health/social services providers to build and maintain effective relationships with physicians, site leadership, hospital staff, and other community stakeholders.

Team Lead Responsibilities (if applicable)

• Provide regular oversight (including field accompaniment) of new hires and ensure adherence to program standards.
• Implement improvement and development plans as needed.
• Utilize leadership principles to mobilize the team toward achieving positive outcomes.
• Conduct follow-up on outstanding matters to ensure successful resolution.
• Represent program interests at internal and external meetings.
• Collect and analyze key statistics (e.g., disease registries, biometrics, care management productivity) to ensure adherence to care management protocols and benchmarks.
• Investigate methods for improving service delivery.
• Complete chart reviews and facilitate peer review processes among assigned staff.
• Use data to implement individual and program-level performance improvement activities (e.g., standardization of care, establishment of disease and population health metrics).
• Assess training needs of new and existing staff; coordinate continuing education, in-services, and staff development opportunities.

Requirements

• High school diploma or equivalent, with strong communication and organizational skills.
• 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 substitute for experience.

Skills

• Organized and motivated in a fast-paced environment.
• Able to manage multiple tasks/projects simultaneously.
• Proficient in quickly reviewing and assessing needs.
• Strong computer software and data file skills.
• Comfortable with continuous change and self-initiating.
• Able to complete documentation efficiently (legal medical records and care management software).
• Maintain strict confidentiality.
• Promote programs and services to the community.
• Build effective and trusting relationships with patients and peers.
• Use motivational interviewing and active-listening skills when assessing patient conditions, problems, and interests.
• Apply conflict-resolution skills to reach consensus on care plans and treatment decisions.
• Demonstrate confidence, compassion, political savvy, and attention to detail.
• Use data to analyze trends and verify accuracy.