Population Health Care Manager, Team Lead

Location
North Carolina, United States
Posted
26 May 2019
End of advertisement period
26 Jul 2019
Ref
401584117
Contract Type
Permanent
Hours
Full Time

Job Description

The Team Lead is a role developed to work in coordination with the PHMO leadership in an assigned program to ensure that the work of care management staff is accomplished effectively.  Responsible for 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.
 
General Description of the Job Class

The 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.

Duties and Responsibilities of this Level

Coordinate 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 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.
 
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.

The intent of this job description is to provide a representative and level of the types of duties and responsibilities that will be required of positions given this title and shall not be construed as a declaration of the total of the specific duties and responsibilities of any particular position. Employees may be directed to perform job-related tasks other than those specifically presented in this description.

Location Durham

Duke Entity DIN/Connected Care

Job Family Level G1

Full Time / Part Time FULL TIME

Regular / Temporary Regular

Shift First/Day

Minimum Qualifications

Duke University 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.

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.

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.

Skills:

The work activity and patient acuity levels can create a stressful atmosphere, therefore individuals successful in this job are: 

  • Organized and motivated by a fast-paced environment 
  • Able to manage multiple tasks/projects simultaneously 
  • Proficient in review and assess needs quickly 
  • Strong with the use of computer software tools and data files 
  • Comfortable with continuous change and self-initiating 
  • Able to complete documentation in a quick and efficient manner (will be in legal medical record and other software systems developed for care management and population based program metrics)

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