Auto req ID
109982BR
Duke Entity
DIN/Connected Care
Job Code
5556 POPULATION HEALTH SPECIALIST
Job Description
Occ SummaryThe Population Health Specialist will develop, implement, and evaluatecomprehensive patient plans to ensure that patients receive appropriateoverall medical care,therapy and training services, in an effort to enable their recovery ormanagement of complex,chronic healthconditions.The Population Health Specialist is responsible and accountable forsupporting clinical expertisefor specific complex patient populations. This role will performsupporting clinical diseasemanagement, assessment of disease states and utilization, care plandevelopment and facilitation,referral to appropriate levels of care, etc. The Population HealthSpecialist functions as an integralpart of an interdisciplinary team, ensuring excellence in patient care,in an effort to achieve optimalclinical outcomes through a seamless model of access and care. Focuson improving transitions incare for patients, physicians, family and community.Patient base consists of patients who are sub-optimal users ofhealthcare and/or management ofchronic disease. Identify any barriers to proper utilization anddetermine best steps for followingtreatment recommendations, as well as providing resource/benefiteducation, counseling and self-care processes. Focus on improving transitions in care for patients,physicians, family andcommunity.The PopulationHealth Specialist will work as an integral part of aninterdisciplinary team, ensuringexcellence in patient care, in an effort to achieve optimal clinicaloutcomes through a seamlessmodel of access and care.Work PerformedAssess patient's condition, locate appropriate treatment and resources,goals.ensure continuity of care and document treatment progression; provideindividual counselingsessions concerning rehabilitation treatment and health maintenance.Document interventionswithin medical record system(s) to collaborate with health careprovidersand monitor treatment programs. Assess the overall health and healtheducation needs of thepatient. Review patient data related to disabilities or medicallimitations and maintain liaison withprimary health care provider.Participate in multi-disciplinary teams to promote a healthy context orsocial environment;developing and supporting local partnerships to broaden the localresponse to health inequalitiesand advocate for patient acting in support providers.Review and evaluate Admission, Discharge and Transfer (ADT) electronicalerts, electronicmedical record notes or other patient trend data. Use communicationsystems and telephoneconsultation in order to ascertain needs of identified patients.Conduct community, telephone andpractice encounters with patients and other care managementteam members to identify care plans, barriers and Follow-up withpatients and providers onidentified health care needs and identify possible resources to addressthose concerns and/or workwith care management team to address concerns in a multi-disciplinarymethod.Facilitate and manage referrals from referral specialist, providers,and other care managementstaff to ensure that identified red flags and healthcare needs ofpatients are addressed.Provide individual consults to patients on health education issues.Develop the health awarenessof individuals, as well as groups and organizations, empowering them tomake better healthchoices.Provide specialized treatment, implementation of care plans, andeducation to patients whileexercising discretion and independent judgment; following establishedpolicies and procedures.Assess the educational needs of the patient/caregiver as it relates tothe disease process,alterations in function, and assimilation back into the home andcommunity. Address the totalneeds of the individual: medical, psychosocial, behavioral, andspiritual.Monitor access to care, services, and treatment including linkage tothe medical home.Involve the patient and their support systems (i.e. caregiver, family,etc.) in the decision-makingprocess. Use proven processes to measure patient’s understanding andacceptance of theproposed plan(s), willingness to change, and support to maintain healthbehavior change. Applyteaching and learning theories to assist patients and families withphysical and emotional impact ofbody changes and chronic illness. Document and communicate with allprovider(s) and member(s)of the care team as needed to minimize fragmented care. This willinclude navigating transitions ofcare – generally from hospital to home or community facilities. Monitorquality and effectiveness ofinterventions to the population by setting long term and/orshort-term specific, measurable goal(s). Determine patient care planusing data from multiplesources such as patient medical records, claims, and program metricreports to prioritizeindividuals for outreach, education, and intervention. Participate inquality/performanceimprovement projects and provide presentations of outcomes in variousgroup settings, includingprovider and practice meetings, as needed.This position may require home visits however; position specificdetails and duties are availableupon request.The work activity and patient acuity levels can create a stressfulatmosphere.Knowledge, Skills and AbilitiesThe work activity and patient acuity levels can create a stressfulatmosphere, 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 recordand other software systems developed for care management and populationbased programmetrics)Level CharacteristicsAdditional job expectations include the ability to:-- Maintain strict confidentiality-- Promote programs and services to community-- Build effective and trustingrelationships with patient/peers-- Use motivational interviewing and active-listening skills whenassessing patient conditions,problems and interests-- Use conflict-resolution skills when reaching consensus about plansof care and treatmentdecisions-- Demonstrate confidence, compassion, political savvy, as well asattention to detail to applythese skills as decisions dictate-- Use data to analyze trends and to verify data
Location
Durham
Requisition Number
401558445
Position Title
POPULATION HEALTH SPECIALIST
Shift
First/Day
Job Family Level
F1
Full Time / Part Time
FULL TIME
Regular / Temporary
Regular
Department Name
Population Health Management Office
Minimum Qualifications
Duke University is an Affirmative Action/Equal Opportunity Employercommitted to providing employment opportunity without regard to anindividual's age, color, disability, gender, gender expression, genderidentity, 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 robustexchange of ideas—an exchange that is best when the rich diversity ofour perspectives, backgrounds, and experiences flourishes. To achievethis exchange, it is essential that all members of the community feelsecure and welcome, that the contributions of all individuals arerespected, and that all voices are heard. All members of our communityhave a responsibility to uphold these values.
Essential Physical Job Functions:Certain jobs at Duke University and Duke University Health System mayinclude essential job functions that require specific physical and/ormental abilities. Additional information and provision for requests forreasonable accommodation will be provided by each hiring department.

Education

Bachelor's degree in business, behavioral/social sciences, public healthor 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 inSocial Work, Disease Management, and experience working directly withPhysicians and Advanced Practice Providers is strongly preferred.

Degrees, Licensures, Certifications

N/A