Population Health Care Manager- Resource Center Team Lead
Duke University Health System
Location: Durham, North Carolina
Internal Number: 160955
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.
Durham, North Carolina Remote – primarily telephonic, work from home with occasional in-office
The Resource Center Clinical Team Lead works in collaboration with the PHMO and Duke inpatient case management leadership to ensure that the work of the Resource Center is accomplished effectively. Responsible for day-to-day supervision of assigned team. In collaboration with the managers, identifies plans and executes activities to promote effective care management and to ensure compliance according to policies and procedures. BSN strongly preferred.
Monday-Friday, occasional Saturday and holiday hours.
The Resource Center Population Health Care Manager Team Lead works 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. Responsible for day-to-day supervision of assigned team. 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
Responsible for understanding the day-to-day work of the team in order to assist team members in any job function when needed, 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.
· Monitor team outcomes to include:
Timely completion of post-discharge phone calls to patients, complete and accurate documentation and communication to pertinent care team members, and
Communicate effectively with discharging providers, inpatient case management, primary care and specialty practices.
Coordinate and facilitate timely care transition needs to include home health, Durable Medical Equipment (DME), and community resources.,
Coordinate 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.
· 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 discharge plan(s) and his/her willingness and ability to adhere to the plan,. Apply teaching and learning theories to assist patients and families with physical and emotional impact of body changes and chronic illness.
· 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. This position may require home visits based on business rules and clinical need of identified patient population.
· Develop and maintain positive relationships with customers internal and external to Duke Health System
· Demonstrate the ability to effectively multi-task in a fast-paced environment, managing multiple priorities.
Knowledge, Skills & Abilities:
3 years of clinical experience required.
Inpatient Case Management, care transitions, discharge planning experience strongly preferred.
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.
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, 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, or current licensure as a Licensed Addiction Specialist by the state of North Carolina. Requires ACM or CCM certification within 3 years of hire date or by December 31, 2020.
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Essential Physical Job Functions: Certain jobs at Duke University and Duke University Health System may include essentialjob 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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