Remote Population Health Jobs in Raleigh, NC (NOW HIRING)

Duke Connected Care 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 its surrounding areas. Job Summary The Population Health Specialist will develop, implement, and evaluate comprehensive patient plans to ensure patients receive appropriate overall medical care, therapy and training services, enabling recovery or management of complex, chronic health conditions. This role supports clinical expertise for specific complex patient populations, performs disease management, assesses disease states, creates care plans, facilitates referrals and coordinates care to improve transitions for patients, physicians, families and the community.

The population base includes patients who are sub‐optimal users of healthcare and/or have trouble managing chronic disease. Hours Full‐time, remote opportunity. Work Performed Assess patients' conditions, locate appropriate treatment and resources, ensure continuity of care and document treatment progression; provide individual counseling about rehabilitation treatment and health maintenance.

Document interventions within medical record systems to collaborate with providers and monitor treatment programs. Assess overall health and health education needs of patients, review disability or medical limitation data, and maintain liaison with primary providers. Participate in multidisciplinary teams to promote a healthy environment, develop local partnerships to address health inequalities and advocate for patient support.

Review and evaluate ADT electronic alerts and other patient trend data. Use communication systems and telephone consultations to ascertain needs, conduct community, telephone and practice encounters to identify care plans, barriers and goals. Follow‐up with patients and providers on identified health care needs and resources.

Facilitate referrals to ensure healthcare needs are addressed. Provide individual consultations on health education issues, develop health awareness, empower patients and families, and implement care plans. Monitor access to care, services and treatment, including linkage to the medical home.

Use proven processes to assess patient understanding and acceptance of the plan, willingness to change, and support health behavior change. Apply teaching and learning theories to assist patients in coping with illness. Document and communicate with all members of the care team to minimize fragmented care and navigate transitions of care from hospital to home or community facilities.

Monitor quality and effectiveness of interventions, set specific measurable goals, and participate in quality/performance improvement projects. Home visits may be required. Working in this role can create a stressful atmosphere due to the acuity of patients.

Knowledge, Skills and Abilities The successful candidate is: Organized and motivated by a fast‐paced environment Ability to manage multiple tasks and projects simultaneously Proficient in reviewing and assessing needs quickly Strong with the use of computer software tools and data files Comfortable with continuous change and self‐initiating Can complete documentation quickly and efficiently in legal medical record systems and other care management and population‐based program metrics software Level Characteristics Additional expectations include the ability to: Maintain strict confidentiality Promote programs and services to the community Build effective and trusting relationships with patients and peers Use motivational interviewing and active listening skills when assessing patient conditions, problems and interests Use conflict‐resolution skills when reaching consensus about plans of care and treatment decisions Demonstrate confidence, compassion, political savvy and attention to detail when using these skills Use data to analyze trends and verify data Minimum Qualifications Education: Bachelor's degree in business, behavioral/social sciences, public health or a related population health field. Experience: At least 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 in social work, disease management, and direct work with physicians and advanced practice providers is strongly preferred.

Degrees, Licensures, Certifications: N/A Equal Opportunity Employer Duke is an 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 (including pregnancy and pregnancy related conditions), sexual orientation or military 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.

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