Population Health Care Manager

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.

Hours:  10a.m.-6:30p.m. M-F

The Population Health Care Manager provides clinical expertise for complex and rising-risk patient populations, supporting specific contractual and program requirements. This role focuses on improving health outcomes for individuals with chronic conditions and complex medical, behavioral health, and psychosocial needs through comprehensive care management, disease management, patient education, and coordination of services. As a key member of an interdisciplinary care team, the Population Health Care Manager promotes seamless transitions of care, enhances patient engagement, and ensures access to appropriate healthcare and community resources.

Key Responsibilities

• Conduct comprehensive assessments to evaluate patients' medical, behavioral health, psychosocial, environmental, financial, and educational needs.
• Develop, implement, and coordinate individualized care plans and evidence-based interventions to improve patient health outcomes.
• Perform disease and chronic condition management for complex and high-risk patient populations.
• Utilize medical records, claims data, and program performance metrics to identify patients for targeted outreach, education, and intervention.
• Facilitate connections to primary care providers, specialty services, behavioral health resources, and community-based programs.
• Engage patients, caregivers, and support systems in care planning and shared decision-making processes.
• Employ a patient-centered approach that addresses medical, psychosocial, behavioral, and spiritual needs.
• Assess patient readiness for change and support self-management strategies that encourage long-term health behavior improvement.
• Educate patients and families regarding chronic disease management, treatment plans, and the physical and emotional impacts of illness.
• Establish measurable short-term and long-term goals and monitor the effectiveness of interventions and care plans.
• Maintain accurate and timely documentation in Maestro and other required clinical documentation systems.
• Coordinate care across providers and healthcare settings to reduce fragmentation and improve utilization of services.
• Manage and support transitions of care, including hospital-to-home and community-based care coordination.
• Facilitate communication among primary care providers, specialists, behavioral health professionals, nurses, social workers, and other members of the healthcare team.
• Collaborate with hospitals, physician practices, public health agencies, behavioral health organizations, and community partners to ensure patient engagement in appropriate services.
• Conduct telephonic, community-based, and in-person outreach to patients, providers, and stakeholders.
• Perform home visits as clinically indicated and required by program guidelines.
• Provide recommendations and feedback to leadership regarding care management strategies, payer requirements, quality improvement opportunities, and gaps in care.
• Build and maintain effective relationships with internal and external stakeholders across Duke Health and partner organizations.

Minimum Qualifications

Education

• Bachelor's degree in Nursing, Social Work, Counseling, Therapy, Allied Health, Community Health, or a related clinical field required.

Experience

• Minimum of three (3) years of clinical experience required.

Licensure/Certification Must possess one of the following active North Carolina licenses:

• Registered Nurse (RN) with current North Carolina or compact state licensure
• Licensed Clinical Social Worker (LCSW)
• Licensed Professional Counselor (LPC)
• Licensed Addiction Specialist (LAS)

Certification Requirement

ACM (Accredited Case Manager) or CCM (Certified Case Manager) certification required within three (3) years of hire.