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POPULATION HEALTH PROGRAM COORDINATOR

Employer
Duke University
Location
NPCC MEDICAID

Job Details

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.

Assessment and Intervention:

  • Adhere to the population-based, consultative role of the primary care behavioral health model. Provide flexible consultation services within the emergency department(ED) as needed per the request of providers within the ED.
  • Assist providers and case management staff in assessing mental 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.
  • Work with staff to in identifying and the development of behavioral change plans that are devised with input from patient to assist with reentry to the community.
  • 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 outreach and targeted interventions to patients who have screened positive for behavioral health concerns with need of additional follow-up.
  • Provide individual targeted treatment to address barriers and identified concerns on positive screenings. Provide targeted counseling to address identified concerns.
  • 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.
  • Providing support that encourages appropriate treatment recommendations.
  • 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 rounds with ED staff to assist in identifying patient needs and begin the discharge collaboration process in an effort to provide immediate and impactful care within the emergency department.
  • 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 care management team and assist with engaging in appropriate services. Assist patients to re-connect with existing MH/SA provider and connect patients to Alliance Behavioral Healthcare Customer Service Call Center if they don't an existing provider.
  • Alert MH/SA providers when patients have entered ED to ensure that an immediate follow up appointment occurs. Collect, analyze, and report data for resource utilization by completing a spreadsheet with information about the patients served. Collaborate with other providers and case managers serving the patient to ensure continuity of care and avoid duplication of services.
  • Provide coordination of care between medical health and mental health providers. Collaborating patients with mental health/substance abuse diagnoses and develops strategies to meet the needs of these patients. Works closely with NPCC care management/Alliance care coordination staff to connect these patients to services with the goal of a reduction in hospital/ED utilization.
  • Electronically documents all activity in Maestro, and other documentation systems relevant to the position. In addition, provides any necessary follow-up interventions that may be required.
  • Electronically documents all activity in Maestro, CMIS, ALPHA and other documentation systems relevant to the position. In addition, provides any necessary follow-up interventions that may be required.
  • Minimum Qualifications

    Education

    Work requires a bachelor's degree. Prefer degree in a clinical or business-related field such as Nursing, Social Work, Therapy, Business, allied health, or community health related fields.

    Experience

    Work requires the ability to plan and administer programs and direct program activities and staff within a specific functional area, acquired through four years of related experience.

    Preference:
    Clinical Licensure

    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.

    Organization

    Read our Diversity Profile History

    Duke University was created in 1924 by James Buchanan Duke as a memorial to his father, Washington Duke. The Dukes, a Durham family that built a worldwide financial empire in the manufacture of tobacco products and developed electricity production in the Carolinas, long had been interested in Trinity College. Trinity traced its roots to 1838 in nearby Randolph County when local Methodist and Quaker communities opened Union Institute. The school, then named Trinity College, moved to Durham in 1892, where Benjamin Newton Duke served as a primary benefactor and link with the Duke family until his death in 1929. In December 1924, the provisions of indenture by Benjamin’s brother, James B. Duke, created the family philanthropic foundation, The Duke Endowment, which provided for the expansion of Trinity College into Duke University.Duke Campus

    As a result of the Duke gift, Trinity underwent both physical and academic expansion. The original Durham campus became known as East Campus when it was rebuilt in stately Georgian architecture. West Campus, Gothic in style and dominated by the soaring 210-foot tower of Duke Chapel, opened in 1930. East Campus served as home of the Woman's College of Duke University until 1972, when the men's and women's undergraduate colleges merged. Both men and women undergraduates now enroll in either the Trinity College of Arts & Sciences or the Pratt School of Engineering. In 1995, East Campus became the home for all first-year students.

    Duke maintains a historic affiliation with the United Methodist Church.

    Home of the Blue Devils, Duke University has about 13,000 undergraduate and graduate students and a world-class faculty helping to expand the frontiers of knowledge. The university has a strong commitment to applying knowledge in service to society, both near its North Carolina campus and around the world.

    Mission Statement

    Duke Science"James B. Duke's founding Indenture of Duke University directed the members of the University to 'provide real leadership in the educational world' by choosing individuals of 'outstanding character, ability, and vision' to serve as its officers, trustees and faculty; by carefully selecting students of 'character, determination and application;' and by pursuing those areas of teaching and scholarship that would 'most help to develop our resources, increase our wisdom, and promote human happiness.'

    “To these ends, the mission of Duke University is to provide a superior liberal education to undergraduate students, attending not only to their intellectual growth but also to their development as adults committed to high ethical standards and full participation as leaders in their communities; to prepare future members of the learned professions for lives of skilled and ethical service by providing excellent graduate and professional education; to advance the frontiers of knowledge and contribute boldly to the international community of scholarship; to promote an intellectual environment built on a commitment to free and open inquiry; to help those who suffer, cure disease, and promote health, through sophisticated medical research and thoughtful patient care; to provide wide ranging educational opportunities, on and beyond our campuses, for traditional students, active professionals and life-long learners using the power of information technologies; and to promote a deep appreciation for the range of human difference and potential, a sense of the obligations and rewards of citizenship, and a commitment to learning, freedom and truth.Duke Meeting

     “By pursuing these objectives with vision and integrity, Duke University seeks to engage the mind, elevate the spirit, and stimulate the best effort of all who are associated with the University; to contribute in diverse ways to the local community, the state, the nation and the world; and to attain and maintain a place of real leadership in all that we do.”

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