General Description of the Job ClassThe Population Health Care Manager is responsible for delivering clinical expertise to manage health care needs of specific patient populations across the continuum of care with a goal of improving patient health outcomes and reducing unnecessary utilization and cost. This role functions as an integral part of an interdisciplinary team and a patient's care team to optimize clinical outcomes through a seamless model of transitions, access, and care. This role focuses on improving the health status and connection to resources, preventive care, hospital follow-up, and ongoing healthcare for individuals with chronic health conditions as well as addressing frequent hospital and emergency department utilization, and medical, behavioral health, and psychosocial needs by performing care management and care coordination functions in a variety of settings that include a patient's home, community, and clinic.
These functions include:- Disease management and chronic disease support
- Timely completion of clinical assessment and patient-centered care plan development, facilitation, and implementation
- Transitional Care Management / care transition support inclusive of functions of placement into the right setting of care (e.g., skilled nursing, assisted living, home with caregiver support)
- Assessment of and connection to resources and treatment for health, social, and behavioral needs
- Patient activation and coordination for quality and preventive care gap closure
- Assistance with and completion of medication reconciliation, access, education, and adherence
- Duties and Responsibilities of this Level
- Manages a designated caseload to complete timely development, completion, and implementation of assessments, care plans, and appropriate interventions for identified patient population to determine patient health, social situation, physical environment, behavioral health, substance use, expressed trauma, economic status, and education to patients while exercising discretion and independent judgment.
- Provides individualized treatment plans 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.
- Performs targeted interventions to assist patients with connection to primary care providers and other health care resources.
- Involves the patient and their support systems (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 through a "whole-person" approach, 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).
- Maintains timely documentation of all care management activity in Maestro, and other documentation systems relevant to the position.
- Effectively communicates and coordinates with appropriate care team members to minimize fragmented care and foster appropriate utilization of services. This includes navigating transitions of care generally from hospital or facility to home or community facilities.
- Facilitates interdisciplinary communication among care team members to include specialists, PCP, RN, psychiatrist and other key providers. Interfaces with key providers across the care continuum (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 and consider ethnic and cultural backgrounds.
- Connects with patients and other care team members in a variety of settings, to include patient homes, community agencies and other locations, primary care practices, and telephone and other virtual platforms. This position may require home visits based on business rules and clinical need of identified patient population.
- Participates in quality assurance/performance improvement activities as requested.
- Provides feedback to Team Lead, management, and executive leadership that will enhance negotiations with payers, improve care management, and/or address gaps in care.
- Develop and maintain positive relationships with customers internal and external to Duke Health System.
- Provide other related duties incidental to the work described herein.
Required Qualifications at this LevelEducation:- Bachelor's degree in Nursing or Master's degree that supports licensure by the NC Board of Licensed Clinical Mental Health Counselors (i.e., counseling, social work, allied/behavioral health).
Experience:- 3 years of relevant clinical experience required.
Degrees, Licensure, and/or Certification:- Candidates with a BSN must have current or compact RN licensure in state of NC
- Candidates with a Master's degree (e.g., psychology, social work, counseling, or related behavioral health program) must have a current licensure by one of the following NC Boards: Licensed Clinical Social Worker (LCSW), Licensed Clinical Addiction Specialist (LCAS), or Licensed Clinical Mental Health Counselor (LCMHC)
- All candidate/employees require a case management certification (ACM, CCM, or ANCC) within 3 years of hire
Knowledge, Skills, and Abilities:- Exceptional verbal/written communication and facilitation skills
- Self-driven and able to work effectively in a self-directed role
- Excellent problem-solving skills
- Effectively able to manage multiple priorities in a fast-paced and evolving environment
- Demonstrates basic computer skills to complete job functions
Distinguishing Characteristics of this LevelThe intent of this job description is to provide a representative and level of the types of duties and responsibilities that will be required of positions given this title and shall not be construed as a declaration of the total of the specific duties and responsibilities of any particular position. Employees may be directed to perform job-related tasks other than those specifically presented in this description.
