POPULATION HEALTH CARE MANAGER

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.

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

Required Qualifications at this Level

Education :

Bachelor's degree in a clinical field such as Nursing, Counseling, Social Work, Therapy, Allied Health, or community health related fields. BSN preferred.

Experience :

3 years 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 Addiction Specialist by the state of North Carolina. Requires ACM or CCM certification within 3 years of hire date.

Requires ACM or CCM certification within 3 years of hire date.

Professional Counselor by the state of NC, or current licensure as a Licensed

Duke is an 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 (including pregnancy and pregnancy related conditions), sexual orientation or military 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 essential job 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.