Population Health Care Manager – Care Transition

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🔥 2 minutes ago

🌲 North Carolina – Remote

🌲 North Carolina – Remote

⏰ Full Time

🟡 Mid-level

🟠 Senior

👔 Manager

👻 Ghost score 13%

What it means: the chance that no one is really hiring for this job.How to read it: 60% or higher means we think this is a ghost. Lower scores are less of a worry.How we score it: age, reposts, open roles vs team size, how fast jobs close, and whether pay is listed.Fine print: an estimate from public data, not a judgment of the company. Real jobs can score high, so treat it as a hint, not a fact.

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Duke Careers

WebsiteLinkedInAll Job Openings

10,000+ employees

Founded 1924

💼 Consulting

🏥 Healthcare

📚 Education

Consulting • Healthcare • Education

Duke Careers is a platform connected to Duke University's rich legacy, established in 1924. It aims to celebrate the centennial of Duke University while providing resources, stories, and interviews that reflect the university's history, current achievements, and future aspirations. A key focus of Duke Careers is to engage with alumni and the community, showcasing the transformative impact of education and leadership within the university.

📋 Description

• Provide clinical expertise, support, and guidance for care transitions of patients discharged from Duke University Health System and other identified hospitals and facilities • Support inpatient case management with discharge disposition functions, including FL2s and referrals to skilled nursing facilities and other facilities • Support discharged patients telephonically through proactive transitional care calls and inbound assistance calls • Perform disease and symptom management, disease assessment, care plan development and facilitation, and referrals to appropriate levels of care • Coordinate and facilitate assessments, care plans, and interventions addressing patients’ medical, social, physical, mental health, substance use, trauma, economic, and educational needs • Provide individual treatment and targeted interventions using patient medical records, claims, and program metric reports • Connect patients with primary care providers and other healthcare resources • Involve patients and support systems in decision-making and promote self-management • Measure patient understanding, acceptance, willingness to change, and support for maintaining health behavior change • Apply teaching and learning theories to assist patients and families with chronic illness and physical and emotional changes • Electronically document all activity in Maestro and other relevant systems • Coordinate with providers and care team members to minimize fragmented care and facilitate transitions between hospitals, homes, and community facilities • Facilitate interdisciplinary communication with 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 feedback to team leadership, management, and executive leadership to improve payer negotiations, care management, and care gaps • Develop and maintain positive relationships with internal and external Duke Health System customers

🎯 Requirements

• 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 • Current license 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 • Requires ACM or CCM certification within 3 years of hire date • Ability to perform clinical assessments, care planning, disease and symptom management, patient education, referrals, and care coordination • Ability to document electronically in Maestro and other relevant documentation 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 committed to providing employment opportunity without regard to age, color, disability, gender, gender expression, gender identity, genetic information, national origin, race, religion, sex, sexual orientation, or military status • Community built on collaboration, innovation, creativity, belonging, diversity, and inclusion • Reasonable accommodation information and provision available for essential physical job functions

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