PROGRAM COORD, COMM HEALTH
PROGRAM COORD, COMM HEALTH
Division of Community Health
Assessment and Intervention:
•Assist providers and case management staff in assessing overall health concerns and psychosocial problems. Conduct functional assessments to determine patient social situation, physical environment, mental health, substance use, expressed trauma, and other behavioral concerns and economic status.
•Perform targeted interventions to assist patients with connection to primary care providers and other health care
resources in order to help patients meet their medical, psycho-social and other needs.
•Provide individual targeted treatment to address barriers and identified concerns on positive screenings.
•Perform home visits; document and distribute findings to the appropriate persons as well as in the required electronic systems. Assure the efficient, effective and appropriate flow of necessary patient and care information to the appropriate providers.
•Identify ongoing patient barriers that may interfere with success and assist patient with addressing those concerns.
•Work directly with Nurse Manager and Medical Director for the JFU program to establish standardized operating procedures
Plan and schedule work priorities daily in accordance with assigned responsibilities, goals and deadlines.
Care Coordination and Care Management:
- Facilitate interdisciplinary communication to include specialists, PCP, psychiatrist and other key providers.
- Provide on-site and telephonic outreach to provide relevant information regarding prior treatment history, diagnoses and patient care components both internally and externally to ensure that services provided are sensitive to the needs of individual patients and take into account ethnic and cultural backgrounds. Participate in geriatric rounds with staff to assist in identifying patient needs and begin the discharge collaboration process in an effort to provide immediate and impactful care within the HBGS and JFU programs.
- Interface with key providers (e.g. discharge planners, social workers, physicians, psychiatrist etc.) within the hospital, primary care practices, public health and social service departments, as well as mental health agencies and other community resources to assure that patients are linked to and engaged in services.
- Facilitate transitions in care by collaborating with JFU care management team and assist with engaging in appropriate services.
- Collaborate with other providers and case managers serving the patient to ensure continuity of care and avoid duplication of services.
- Plan, develop and implement goals and objectives of the JFU program in conjunction with other staff members within the program, Community Health Division and/or associated partners including, but not limited to, Lincoln Community Health, Population Health Management, Division Community Clinics, etc
2566 PROGRAM COORD, COMM HEALTH
Job Family Level
Full Time / Part Time
Regular / Temporary
Duke University 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 essential job 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.
Work requires graduation from an accredited degree program in a clinical, allied health, or community health related field.
Work requires five years of progressive experience in a related field with experience in developing and managing community-based health care services.A master's degree in a related field may be substituted for experience on a 1:1 basis.OR AN EQUIVALENT COMBINATION OF RELEVANT EDUCATION AND/OR EXPERIENCE
Auto req ID
Duke University is an Affirmative Action/Equal Opportunity Employer committed to providing employment opportunity without regard to an individual's age, color, disability, genetic information, gender, gender expression, gender identity, national origin, race, religion, sexual orientation, or veteran status.
Essential Physical Job Functions: Certain jobs at Duke University and Duke University Health System may include essential job 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.