Population Health Care Manager – Care Transition

This is a fully remote position, open to applicants in North Carolina.

📋 Description

• Offer clinical expertise, assistance, and guidance for the care transitions of patients being discharged from Duke University Health System and other designated hospitals and facilities.

• Assist inpatient case management with discharge disposition tasks, including FL2s and referrals to skilled nursing facilities and other institutions.

• Provide telephonic support to discharged patients through proactive transitional care calls and incoming assistance calls.

• Execute disease and symptom management, perform disease assessments, develop and facilitate care plans, and make referrals to appropriate levels of care.

• Coordinate and facilitate assessments, care plans, and interventions that address patients’ medical, social, physical, mental health, substance use, trauma, economic, and educational needs.

• Deliver individual treatment and targeted interventions utilizing patient medical records, claims, and program metric reports.

• Connect patients with primary care providers and additional healthcare resources.

• Engage patients and their support systems in decision-making processes and encourage self-management.

• Assess patient understanding, acceptance, willingness to change, and support for sustaining health behavior modifications.

• Employ teaching and learning theories to assist patients and families dealing with chronic illnesses and changes in physical and emotional health.

• Document all activities electronically in Maestro and other pertinent systems.

• Collaborate with providers and care team members to reduce fragmented care and facilitate transitions between hospitals, homes, and community facilities.

• Promote interdisciplinary communication among specialists, PCPs, RNs, psychiatrists, discharge planners, case managers, social workers, physicians, and community resources.

• Conduct on-site, community, and telephonic outreach to patients, providers, and community stakeholders.

• Provide constructive feedback to team leadership, management, and executive leadership to enhance payer negotiations, care management, and address care gaps.

• Cultivate and sustain positive relationships with both internal and external customers of the Duke Health System.

⛳️ Requirements

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

• A minimum of 3 years of clinical experience is required.

• Current licensure in at least one of the following: current or compact RN licensure in 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.

• ACM or CCM certification must be attained within 3 years of the hire date.

• Competency in performing clinical assessments, care planning, disease and symptom management, patient education, referrals, and care coordination.

• Proficient in electronic documentation using Maestro and other relevant systems.

• Ability to coordinate with interdisciplinary providers, patients, caregivers, families, hospitals, primary care practices, public health and social service departments, mental health agencies, and community resources.

🏝️ Benefits

• Equal Opportunity Employer dedicated to providing employment opportunities without regard to age, color, disability, gender, gender expression, gender identity, genetic information, national origin, race, religion, sex, sexual orientation, or military status.

• A community fostered on collaboration, innovation, creativity, belonging, diversity, and inclusion.

• Information and provisions for reasonable accommodations available for essential physical job functions.