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. General Description of the Job Class The Population Health Care Manager for the Care Transitions Team is responsible for providing clinical expertise, support, and guidance for care transitions of patients being discharged from the Duke University Health System as well as other identified hospitals and facilities. This role consists of two primary functions: Support for inpatient case management with core administrative functions related to discharge disposition prior to discharge e.g., FL2s, referrals to SNFs and other facilities, etc. Support for patients telephonically once they have been discharged through proactive transitional care phone calls as well as receiving phone calls from patients needing assistance post-discharge. The Care Transitions Population Health Care Manager will perform disease and symptom management, assessment of disease, care plan development and facilitation, and referral to appropriate levels of care, etc. The role functions as an integral part of an interdisciplinary team, ensuring excellence with transitions of care to achieve optimal clinical outcomes through a seamless model of access and care. This role has a focus on improving the health status and care for individuals with chronic conditions with complex medical, mental health and psychosocial issues. Duties and Responsibilities of this Level Coordinate and facilitate timely implementation of assessments, care plans, and appropriate interventions for identified patient population to determine patient health, social situation, physical environment, mental health, substance use, expressed trauma, economic status, and education to patients while exercising discretion and independent judgment; following established policies and procedures. Provide individual treatment to address barriers and identified concerns by accessing systematically identified data from multiple sources such as patient medical records, claims, and program metric reports to target recipients and providers for outreach, education, and intervention. Perform targeted interventions to assist patients with connection to primary care providers and other health care resources. Involve the patient and their support systems i.e. caregiver, family, etc. in the decision-making process. Use a patient-centric, collaborative partnership approach to assist the patient with improved self-management and identifying barriers by addressing the total individual, inclusive of medical, psychosocial, behavioral, and spiritual needs. Utilize proven processes to measure a patients understanding and acceptance of the proposed plans, his/her willingness to change, and his/her support to maintain health behavior change. Apply teaching and learning theories to ass
