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 1 year

Personnel Area:DIN/Connected Care

Resource Center: The Resource Center is a team within the Population Health Management Office (PHMO) that focuses on patient care transitions, supporting inpatient case management with discharge planning and completes post-discharge follow up phone calls to patients, assisting them with key components that contribute to improved outcomes post-discharge.

Location

Durham, North CarolinaRemote - primarily telephonic, work from homewith occasional in-office

Hours:

Monday-Friday, occasional Saturday and holiday hours.

General Description

TheResource Center Population Health Care Manager Team Leadworks in collaboration with the PHMO and Duke inpatient case management leadership to ensure that the work of the Resource Center is accomplished effectively and supportive of patient care transitions. The Team Lead is responsible for day-to-day supervision of assigned team and in collaboration with leadership, identifies, plans and executes activities to promote effective transitional care management and ensure compliance according to policies and procedures. 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 Performed

Responsible for understanding the day-to-day work of the team in order to assist team members in any job function, inform processes and programs internal and external to PHMO, and serve as a preceptor for new team members.

Participates in the hiring process for new team members per PHMO policy and procedure.
Supports team members in their work through regularly scheduled one-on-one and team meetings.
Models Duke values.
Works closely with Resource Center leadership and team members to develop, implement, and re-evaluate work flows to ensure they are up-to-date and address best practice.
Monitors team outcomes to include:
- Timely completion of post-discharge phone calls (i.e., transitional care calls) to patients, complete and accurate documentation and communication to pertinent care team members
- Effective communication with discharging providers, inpatient case management, primary care and specialty practices.
- Timely coordination and facilitation of care transition needs to include home health, durable medical equipment (DME), and community resources.
- Coordination of 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.

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 by addressing the total individual, inclusive of medical, psychosocial, behavioral, and spiritual needs.
Utilizes proven processes to measure a patient's understanding and acceptance of the discharge plan(s) and his/her willingness and ability to adhere to the plan. Applies teaching and learning theories to assist patients and families with physical and emotional impact of body changes and chronic illness.

Electronically documents all activity in Epic, and other documentation systems relevant to the position.

Communicates and coordinates with all provider(s) and member(s) of the care team as needed to minimize fragmented care and foster appropriate utilization of services. This includes navigating transitions of care generally from hospital to home or community facilities and home to facility.

Facilitates interdisciplinary communication to include specialists, PCP, RN, psychiatrist and other key providers. Interfaces 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.
Provides 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.

Develops and maintains positive relationships with customers internal and external to Duke Health System.
Demonstrates the ability to effectively multi-task in a fast-paced environment, managing multiple priorities.

Minimum Qualifications

Education

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

Experience

3 years of clinical experience required. Inpatient Case Management, care transitions, discharge planning experience strongly preferred.

Degrees, Licensures, Certifications

Must have a current license in at least one of these areas: current or compact RN licensure in the state of North Carolina. Requires ACM or CCM certification within 3 years of hire date.

Duke 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 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.

POPULATION HEALTH CARE MANAGER
Job Level: G2

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 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.