Population Health Resource Associate
This is a qualifying interview with the Population Health Team.
The interview process consists of four steps. In order to be considered for an interview, you must do the following:
- Apply to the Requisition with an up-to-date resume to include any required certifications.
- A member of Central HR will contact you to conduct a phone screen should you be selected.
- If confirmed, you will receive an email with the time and location for your interview.
- Interviews will be with a member of the Population Health Team.
Please note, there are a limited number of interview spots.
What is Population Health Management?
Look up the phrase "population health management," and you'll find several definitions floating around the Web. At Duke, we define population health management to include all data-informed efforts to improve the health outcomes and health services utilization of an assigned patient panel.
- proactive outreach to patients who are not obtaining recommended preventive care
- delivery of care management services to patients who have uncontrolled chronic disease
- interventions that improve patient engagement and provider access outside of the traditional office-based encounter (e.g., telehealth)
- participation in accountable care organizations, narrow networks or other networks where providers are accountable for the quality and cost of an assigned population
- risk stratification to aid in the delivery of the right care, to the right patient, at the right time
Our transdisciplinary team includes health administrators, IT professionals, providers and over 100 care management professionals. Our goal is to facilitate higher-quality care, which results in a greater return on healthcare dollars.
We achieve our impact in four ways:
- Delivering care management services to eligible patients
- Maintaining provider networks that promote high-quality care and financial accountability
- Supporting in-network providers with performance improvement services
- Participating in national and local initiatives that promote high-quality care and wiser stewardship of healthcare resources
Our Care Management team includes clinical care managers, care specialists, care advocates and enrollment specialists. Experience background includes nurses, social workers, counselors, addiction specialists and varying healthcare related and customer service experience.
There is the option to work from home with frequency dependent upon position.
Our location has free parking and easy access.
General Description of the Job Class
The Population Health Resource Associate will implement, plan and coordinate comprehensive patient plans to ensure that patients receive appropriate overall medical care, therapy and training services, in an effort to enable their recovery or management of complex, chronic health conditions. This work is done in conjunction with the Complex Care Team(s).
Duties and Responsibilities of this Level
Provide outreach and care management support to patients; educate clients of available community resources. Assist clients with coordination of care between healthcare providers and other complex care team(s).
Performs a range of non-clinical care management functions (outreach, health education, informal counseling, social support, resource linkages, interpretation/ translation, transportation coordination, and advocacy) for an active patient caseload to build individual and community capacity by increasing health knowledge and self-sufficiency and accurately documents activities with follow-up and plans of action.
Act as a client advocate and support the development of problem solving skills; provide instructions in basic health care procedures.
Coordinate and/or participate in community health activities to include preparing patient education materials, brochures, bulletins, newsletters and other promotional materials and/or publications. Attend off-site, outreach education and recruitment sessions.
Maintain liaison with other programs, offices and departments at Duke to coordinate program business and to accomplish program objectives. Interface with external organizations as appropriate to ensure cooperative efforts are enhanced and available resources are utilized. Promote program on key coalitions and task forces to foster collaboration, educate constituencies, leverage resources, and reduce duplication of services.
Monitor and evaluate program effectiveness, investigate trends, and recommend and implement modifications to improve program effectiveness. Prepare reports and conduct preliminary analyses setting forth progress and adverse trends.
Perform other related duties incidental to the work described herein.
The work activity and patient acuity levels can create a stressful atmosphere.
Additional responsibilities could include: Make home visits and other contacts with clients, as necessary. Coordinates regular practice visits and attends provider meetings to promote coordination of patient care.
Accompany clients to scheduled appointments and/or referral sites, as needed. Serves as liaison to health/social services providers to build and maintain effective relationships with physicians, site leadership, hospital staff and other community stakeholders to ensure timely and appropriate patient follow-up.
Team Lead Responsibilities: Provides regular oversight (including accompaniment into the field) of new hires and completes required performance adherence to program standards and implements improvement and development plans as needed. Utilize leadership principles to mobilize team to achieve positive outcomes. Conduct follow-up on outstanding matters to insure they are successfully resolved. Represents program interests at internal and external meetings. Collect and analyze key statistics (disease registries, biometrics, care management productivity, etc.) to ensure adherence to established care management protocols and benchmarks and investigates methods for improving service delivery. Complete chart reviews and facilitate peer review process among assigned staff members Utilizes data to implement individual and program-level performance improvement activities (standardization of care, establishment of disease and population health metrics, consistency of reporting, information flow and management, job functions). Assess training needs of new and existing staff, identifies and coordinates continuing education, in-services and staff development opportunities to ensure that skill-sets adhere to established core competencies.
Duke Entity DIN/Connected Care
Job Family Level C2
Full Time / Part Time FULL TIME
Regular / Temporary Regular
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.
High school degree or equivalent, as well as strong communications and organizational skills.
Work generally requires customer service experience through patient or public contact.Two years of experience with customer interactions via phone and marketing/communications preferred.Active user of electronic medical records software strongly preferred.An associate’s degree or higher may be substituted for experience.
Degrees, Licensures, Certifications