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.

The Population Health Management Office is a multidisciplinary team focused on partnering with patients, providers, payers, and communities to measurably improve health outcomes through results-driven care management, evidence-based practice support, and actionable analytics. 

PHMO's vision:  Connected patients, empowered providers, healthy communities.

Location: 

Population Health Management Office – physical location within Duke Primary Care's hospital follow-up clinic located in Durham, North Carolina

Duke Primary Care's  hospital follow-up clinic is located within the Duke Primary Care Riverview location in North Durham. DPC Riverview is a primary care clinic in Durham offering internal medicine care and lab services in one convenient location. They provide personalized care for adult people in a comfortable environment. 

Hours: 

Monday-Friday 8am-5pm

General Description of the Job Class

The Population Health Management Office (PHMO) seeks a Population Health Care Manager whose primary physical location will be at .  This Population Health Care Manager is an integral part of an interdisciplinary team that includes PHMO and Duke Primary Care post-discharge team members. This role is focused on supporting care transitions for individuals recently discharged from the hospital in order to achieve optimal health outcomes through a seamless model of access and care. This position performs key functions of transitional care management in-person in clinic, virtually, and telephonically, including:

• Identifies and addresses medication discrepancies, patient understanding of their prescribed medication dosing/regimen, barriers to patient obtaining their prescribed medications, etc.
• Screens for social drivers of health and helps connect patients to community-based resources
• Educates and reinforces hospital follow-up plan of care
• Identifies and addresses barriers to health care and provides connection to the appropriate resources
• Communicates pertinent information with the patient's health care team
• Disease management, assessment of disease, care plan development and facilitation, referral to appropriate levels of care, etc.

Duties and Responsibilities of this Level

• Coordinates and facilitates timely development and implementation of assessments, care plans, and appropriate interventions for identified patient population to determine patient health, social situation and needs, physical environment, behavioral health, substance use, expressed trauma, economic status, and education to patients while exercising discretion and independent judgment; all within established policies and procedures.
• Addresses identified barriers and concerns by accessing the appropriate 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.
• Performs targeted interventions to assist patients with connection to primary care providers and other health care resources.
• Involves the patient and their support system(s) (i.e. caregiver, family, etc.) in the decision-making process.
• Uses 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.
• Utilizes proven processes to measure a patient's understanding and acceptance of the proposed plan(s), his/her willingness to change, and his/her support to maintain health behavior change.
• Applies teaching and learning theories to assist patients and families with physical and emotional impact of body changes and chronic illness.
• Monitors quality and effectiveness of interventions to the population by setting long term and/or short-term specific, measurable goal(s).
• Electronically documents all activity in Maestro, and other documentation systems relevant to the position.
• Communicates and coordinates with pertinent provider(s) and member(s) of the care team as needed to minimize fragmented care and foster appropriate utilization of services. This includes navigating transitions of care generally from hospital to home or community facilities.
• Facilitates interdisciplinary communication to include specialists, PCP, RN, psychiatrist and other key providers. Interfaces with key providers (e.g. discharge planners, social workers, physicians, psychiatrist etc.) within the hospital, primary care practices, public health and social service departments, as well as behavioral health agencies and other community resources to assure that patients are linked to and engaged in services.
• Provides 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, including ethnic and cultural backgrounds.
• This position may require home visits based on business and clinical needs of the identified patient population.
• Provides feedback to supervisor and other leadership that promotes best-in-class care management and/or addresses gaps in care.
• Develops and maintains positive relationships with customers internal and external to Duke Health System.

 Required Qualifications at this Level

Duke is an Affirmative Action/Equal Opportunity Employer committed to providing employment opportunity without regard to an individual's age, color, disability, gender, gender expression, gender identity, genetic information, national origin, race, religion, sex, sexual orientation, or veteran status.

Duke aspires to create a community built on collaboration, innovation, creativity, and belonging. Our collective success depends on the robust exchange of ideas—an exchange that is best when the rich diversity of our perspectives, backgrounds, and experiences flourishes. To achieve this exchange, it is essential that all members of the community feel secure and welcome, that the contributions of all individuals are respected, and that all voices are heard. All members of our community have a responsibility to uphold these values.

Essential Physical Job Functions: Certain jobs at Duke University and Duke University Health System may include essentialjob 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.