Population Health Care Manager- QuEST Team

Overview

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 its surrounding areas.

Population Health Care Manager is responsible for delivering clinical expertise to manage healthcare needs of specific patient populations across the continuum of care with the 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.

The focus is on improving 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, medical, behavioral health, and psychosocial needs by performing care management and care coordination functions within the Education and Quality Team.

Quality Assurance, Auditing, Regulatory Compliance, and Training and Education.

• 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 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.
• Manages a designated caseload to complete timely development, completion, and implementation of assessments, care plans, and appropriate interventions for identified patient population.
• 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.
• 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.
• Utilizes proven processes to measure a patient’s understanding and acceptance of the proposed plan(s).
• 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 short‑ and long‑term specific, measurable goals.
• 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, including navigating transitions of care from hospital or facility to home or community facilities.
• Facilitates interdisciplinary communication among care team members and interfaces with key providers across the care continuum.
• Provides on‑site, community, and telephonic outreach to patients, providers, and community stakeholders to identify treatment history and ensure services are sensitive to individual needs, including ethnic and cultural backgrounds.
• Connects with patients and other care team members in a variety of settings, including patient homes, community agencies, primary care practices, telephone and other virtual platforms. This position may require home visits based on business rules and clinical need.
• Participates in quality assurance/performance improvement activities as requested.
• Provides feedback to Team Lead, management, and executive leadership to enhance negotiations with payers and improve care management.
• Develops and maintains positive relationships with customers internal and external to…