Population Health Care Manager-Embedded at Lincoln Community Health Center

Duke University - Durham, NC

Full-time - Mid Level

Durham, NC

Educational Services

About the position

The Population Health Care Manager at Duke University Health System is responsible for managing the healthcare needs of specific patient populations to improve health outcomes and reduce unnecessary healthcare utilization and costs. This role involves working as part of an interdisciplinary team to provide care management and coordination, focusing on chronic health conditions and addressing medical, behavioral health, and psychosocial needs through various settings, including home visits.

Responsibilities

• Manage a designated caseload to develop, complete, and implement assessments and care plans for patients.
• Provide individualized treatment plans to address barriers and concerns using data from multiple sources.
• Perform targeted interventions to connect patients with primary care providers and healthcare resources.
• Involve patients and their support systems in the decision-making process.
• Utilize a patient-centric approach to assist patients with self-management and identify barriers to care.
• Monitor the quality and effectiveness of interventions and set measurable goals.
• Maintain timely documentation of all care management activities in relevant systems.
• Communicate and coordinate with care team members to minimize fragmented care.
• Facilitate interdisciplinary communication among care team members and external providers.
• Conduct outreach to patients and community stakeholders to ensure sensitive and appropriate service delivery.

Requirements

• Bachelor's degree in Nursing or a Master's degree in a related field.
• 3 years of relevant clinical experience.
• Current or compact RN licensure in the state of NC for BSN candidates.
• Licensure by NC Boards for Master's degree candidates (LCSW, LCAS, LCMHC).
• Case management certification (ACM, CCM, or ANCC) within 3 years of hire.
• Exceptional verbal/written communication and facilitation skills.
• Self-driven with the ability to work effectively in a self-directed role.
• Excellent problem-solving skills and ability to manage multiple priorities.

Nice-to-haves

• Behavioral health experience is highly preferred.
• Experience with care management and coordination in a clinical setting.

Benefits

• $7,500 Commitment Bonus for external candidates paid over 1 year.