Population Health Specialist- Medicaid

Duke Connected Care, a community-based, physician-led network, includes a group of doctors, hospitals and other healthcare providers who work together to deliver high-quality care to Medicare Fee-for-Service patients in Durham and itssurrounding areas.

The Population Health Specialist will develop, implement, and evaluate 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.

The Population Health Specialist is responsible and accountable for supporting clinical expertise for specific complex patient populations. This role will perform supporting clinical disease management, assessment of disease states and utilization, care plan development and facilitation, referral to appropriate levels of care, etc. The Population Health Specialist functions as an integral part of an interdisciplinary team, ensuring excellence in patient care, in an effort to achieve optimal clinical outcomes through a seamless model of access and care. Focus on improving transitions in care for patients, physicians, family and community.

Patient base consists of patients who are sub-optimal users of healthcare and/or management of chronic disease. Identify any barriers to proper utilization and determine best steps for following treatment recommendations, as well as providing resource/benefit education, counseling and self-care processes. Focus on improving transitions in care for patients, physicians, family and community.

The Population Health Specialist will work as an integral part of an interdisciplinary team, ensuring excellence in patient care, in an effort to achieve optimal clinical outcomes through a seamless model of access and care.

Duties and Responsibilities of this Level

• Completes hospital follow-up phone calls (transitional care calls) to patients discharged from a DUHS or other outside hospital and primarily identified as moderate risk for readmission:

Prioritizes individuals for outreach, education, and intervention using data from multiple sources such as patient

• • medical records, claims, program reports (e.g., Readmission Risk Report, Care Companion survey responses)
  • Assesses patient's condition by reviewing appropriate hospital admission and discharge notes and conducts a telephonic transitional care call assessment of patient needs; escalates patient to a Resource Center PHCM if assessment indicates
  • Evaluates and addresses patient needs, which can include researching the appropriate resources to address the needs, and referring using the appropriate channel(s)
  • Provides single medical or behavioral health condition education concerning individualized hospital follow-up and discharge needs
  • Documents interventions within medical record system(s) via case management notes and the TCM Outreach Flowsheet to collaborate with health care providers and monitor treatment programs
  • Involves the patient and their support systems (i.e. caregiver, family, etc.) in the decision-making process
  • Uses proven processes (e.g., Motivational Interviewing) to measure patient’s understanding and acceptance of the proposed plan(s), willingness to change, and support to maintain health behavior change
  • Applies teaching and learning theories to assist patients and families with physical and emotional impact of body changes and chronic illness
  • Reviews and evaluates discharge notifications and reports, electronic medical record notes or other patient trend data using the Readmission Risk Report and electronic medical record
• Participates in multi-disciplinary teams to promote a healthy context or social environment
  • Multi-disciplinary team participation includes Population Health Care Manager, Population Health Resource Associate, Pharmacist/Pharmacy Technicians, and Medical Director via case conferences and ad hoc consultation.
• Documents and communicates with appropriate care team members as needed to minimize fragmented care and address patient needs. This includes navigating transitions of care – generally from hospital to home or community facilities

• Participates in quality/performance improvement projects. Examples of QI projects: Care Companion and Community Skilled Nursing Facility (SNF) placement workgroup

Required Qualifications at this Level

Education: Bachelor's degree in business, behavioral/social sciences, public health or related population health field.

Experience: 

Work requires three years of experience in a business, behavioral/ social sciences, public health or related population health field.

Sales and Marketing background, along with professional experience in Social Work, Disease Management, and experience working directly with Physicians and Advanced Practice Providers is strongly preferred.

Degrees, Licensure, and/or Certification: N/a

Knowledge, Skills, and Abilities:

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)

Duke 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 essentialjob 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.