Duke Careers

Population Health Care Manager – Complex Case Manager

Duke Careers

full-time

Posted on:

Location Type: Office

Location: Durham • North Carolina • United States

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About the role

  • Coordinate and facilitate timely implementation of assessments, care plans, and appropriate interventions for identified patient population to determine patient health, social situation, physical environment, mental health, substance use, expressed trauma, economic status, and education to patients while exercising discretion and independent judgment; following established policies and procedures.
  • Provide individual treatment to address barriers and identified concerns by accessing systematically identified 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.
  • Perform targeted interventions to assist patients with connection to primary care providers and other health care resources.
  • Involve the patient and their support systems (i.e. caregiver, family, etc.) in the decision-making process.
  • Use 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.
  • Utilize proven processes to measure a patients understanding and acceptance of the proposed plan(s), his/her willingness to change, and his/her support to maintain health behavior change.
  • Apply teaching and learning theories to assist patients and families with physical and emotional impact of body changes and chronic illness.
  • Monitor quality and effectiveness of interventions to the population by setting long term and/or short-term specific, measurable goal(s).
  • Electronically document all activity in Maestro, and other documentation systems relevant to the position.
  • Communicate and coordinate with all provider(s) and member(s) of the care team as needed to minimize fragmented care and foster appropriate utilization of services.
  • This will include, navigating transitions of care generally from hospital to home or community facilities.
  • Facilitate interdisciplinary communication to include specialists, PCP, RN, psychiatrist and other key providers.
  • Interface 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 mental health agencies and other community resources to assure that patients are linked to and engaged in services.
  • Provide 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 and take into account ethnic and cultural backgrounds.

Requirements

  • Bachelor's degree in a clinical field such as Nursing, Counseling, Social Work, Therapy, Allied Health, or community health related fields.
  • 3 years of clinical experience required.
  • 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 Professional Counselor by the state of NC, Current licensure as a Licensed Addiction Specialist by the state of North Carolina.
  • Requires ACM or CCM certification within 3 years of hire date.
Benefits
  • 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.
  • 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.
Applicant Tracking System Keywords

Tip: use these terms in your resume and cover letter to boost ATS matches.

Hard Skills & Tools
patient assessmentscare plansinterventionsdata analysistreatment planningpatient educationquality monitoringdocumentationtelephonic outreachcommunity outreach
Soft Skills
discretionindependent judgmentcollaborative partnershipcommunicationdecision-makinginterdisciplinary communicationcultural sensitivityempathyproblem-solvingpatient advocacy
Certifications
RN licensureLicensed Clinical Social WorkerLicensed Professional CounselorLicensed Addiction SpecialistACM certificationCCM certification