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 Resource Associate will implement, plan and coordinate comprehensive patient plans to ensure that patients receive appropriate overall medical care, therapy and training services, in an effort to enable their recovery or management of complex, chronic health conditions. This work is done in conjunction with the Complex Care Team (s ).

Duties and Responsibilities of this Level

Provide outreach and care management support to patients; educate clients of available community resources. Assist clients with coordination of care between healthcare providers and other complex care team(s).

Performs a range of non-clinical care management functions (outreach, health education, informal counseling, social support, resource linkages, interpretation/ translation, transportation coordination, and advocacy) for an active patient caseload to build individual and community capacity by increasing health knowledge and self-sufficiency and accurately documents activities with follow-up and plans of action.

Act as a client advocate and support the development of problem solving skills; provide instructions in basic health care procedures.

Coordinate and/or participate in community health activities to include preparing patient education materials, brochures, bulletins, newsletters and other promotional materials and/or publications. Attend off-site, outreach education and recruitment sessions.

Maintain liaison with other programs, offices and departments at Duke to coordinate program business and to accomplish program objectives. Interface with external organizations as appropriate to ensure cooperative efforts are enhanced an d available resources are utilized. Promote program on key coalitions and task forces to foster collaboration, educate constituencies, leverage resources, and reduce duplication of services.

Monitor and evaluate program effectiveness, investigate trends, and recommend and implement modifications to improve program effectiveness. Prepare reports and conduct preliminary analyses setting forth progress and adverse trends.

Perform other relatedduties incidental to the work described herein.

The work activity and patient acuity levels can create a stressful atmosphere.

Additional responsibilities could include:

-- Make home visits and other contacts with clients, as necessary. Coordinates regular practice visits and attends provider meetings to promote coordination of patient care.

-- Accompany clients to scheduled appointments and/or referral sites, as needed.

-- Serves as liaison to health/social services providers to build and maintain effective relationships with physicians, site leadership, hospital staff and other community stakeholders to ensure timely and appropriate patient follow-up.

Minimum Qualifications

Education

High school degree or equivalent, as well as strong communications and organizational skills.

Preferred skills in Behavioral and/or Public Health background. The AMH+ team is working with a specific population. 

Experience

Work generally requires customer service experience through patient or public contact. Two years of experience with customer interactions via phone and marketing/communications preferred. Active user of electronic medical records software strongly preferred. An associate’s degree or higher may be substituted for experience.

Degrees, Licensures, Certifications

NA

Duke 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.

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Essential Physical Job Functions: Certain jobs at Duke University and Duke University Health System may include essentialjob 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.