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Full Time
11/8/2024
Durham, NC 27703
(26.2 miles)
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.External Candidates eligible for a $7,500.00 Commitment Bonus paid over one yearThe Population Health Care Manager is responsible for clinical expertise for specific complex and/or rising risk patient populations with a design to meet specific contractual and program related requirements. This role will perform disease management, assessment of disease, care plan development and facilitation, 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. Focus on improving the health status and care for individuals with chronic conditions with complex medical, mental health and psychosocial issues.Work PerformedCoordinate 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 t o 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.This position may require home visits based on business rules and clinical need of identified patient population.Provide feedback to TL, 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.Minimum QualificationsEducationBachelor's degree in a clinical field such as Nursing, Counseling, Social Work, Therapy, Allied Health, or community health related fields.Experience3 years of clinical experience required.Degrees, Licensures, CertificationsMust have a current license in at least one of these areas:Current or compact RN licensure in the state of North CarolinaCurrent licensure as a licensed clinical social worker by the NC Social Work Certification and Licensure BoardCurrent 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.POPULATION HEALTH CARE MANAGERJob Level: G2Duke 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 ideasan 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 communityfeel 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.
Full Time
11/7/2024
Durham, NC 27703
(26.2 miles)
At Duke Health, we're driven by a commitment to compassionate care that changes the lives of patients, their loved ones, and the greater community. No matter where your talents lie, join us and discover how we can advance health together.About Duke University HospitalPursue your passion for caring with Duke University Hospital in Durham, North Carolina, which is consistently ranked among the best in the United States and is the number one hospital in North Carolina, according to U.S. News and World Report for 2023-2024. Duke University Hospital is the largest of Duke Health's three hospitals and features 1048 patient beds, 65 operating rooms, as well as comprehensive diagnostic and therapeutic facilities, including a regional emergency/trauma center, an endo-surgery center, and more.Duke Nursing Highlights:Duke University Health System is designated as a Magnet organizationNurses from each hospital are consistently recognized each year as North Carolina's Great 100 Nurses.Duke University Health System was awarded the American Board of Nursing Specialties Award for Nursing Certification Advocacy for being strong advocates of specialty nursing certification.Duke University Health System has 6000 + registered nursesQuality of Life: Living in the Triangle!Relocation Assistance (based on eligibility)External Candidates eligible for a $7,500.00 Commitment Bonus paiid over 1 yearManage a designated caseload to coordinate and complete timely assessment, planning, implementation and evaluation of discharge plans and care transitions across the continuum of care. Ensure optimum utilization of the patient's and the Health System's resources and perform these duties within the requirements of CMS and other external review agencies.Work PerformedMonitor daily census and assignment to assure all patients are assessed.Perform other related duties incidental to the work described herein. Case management needs including care coordination/transition and discharge planning, consultations, advocacy, education. Maintain effective communication with health care team members related to assessment findings, discharge planning needs and provider orders needed to arrange Homecare, Durable Medical Equipment, Transportation, Skilled Nursing or Acute Rehab Facility placement, Substance Abuse Treatment and outpatient follow-up. Maintain working knowledge of specific benefits and reimbursement guidelines, the discharge planning process and applicable federal, state and local regulations. Provide education and guidance on these topics to providers, patients and families as needed. Work with Utilization Management partners to provide information and feedback that will enhance negotiations and denial prevention with payers. Maintain timely documentation of assessment findings, discharge arrangements and actions taken according to departmental guidelines; prepare reports and maintain records as requested and/or required. Participate in Quality Assurance/Performance Improvement (QAPI) activities as requested. Job responsibilities may include site specific duties, weekend/holiday or after hours coverage as designated at each entity. Develop and maintain positive working relationships with customers internal and external to Duke Health System.Knowledge, Skills and AbilitiesAbility to work effectively in a self-directed role Ability to multi-task, capable of daily problem-solving complex issues Excellent written and verbal skills Basic computer skills necessaryLevel CharacteristicsN/AMinimum QualificationsEducationBSN or MSW requiredExperience3 years of relevant experienceDegrees, Licensures, CertificationsRequires Case Management Certification (ACM, CCM or ANCC) within 3 years of hire. MSW or BSN required. If BSN must have current or compact RN licensure in state of NC. CASE MANAGERJob Level: G2Duke 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 ideasan 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.
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