Duke University Hospital

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at Duke University Hospital

Posted: 9/26/2019
Job Reference #: 1347987

Job Description

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Duke Entity
DIN/Connected Care

Job Code

Job Description
General Description of the Job Class
The Population Health Specialist will develop, implement, and evaluate
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.

The Population Health Specialist is responsible and accountable for
supporting clinical expertise for
specific complex patient populations. This role will perform
supporting clinical disease
assessment of disease states and utilization, care plan development and
facilitation, referral to
appropriate levels of care, etc. The Population Health Specialist
functions as an integral part of an
interdisciplinary team, ensuring excellence in patient care, in an
effort to achieve optimal clinical
outcomes through a seamless model of access and care. Focus on
improving transitions in care
patients, physicians, family and community.

Patient base consists of patients who are sub-optimal users of
healthcare and/or management of
chronic disease. Identify any barriers to proper utilization and
determine best steps for following
treatment recommendations, as well as providing resource/benefit
education, counseling and self-
processes. Focus on improving transitions in care for patients,
physicians, family and community.

The Population Health Specialist will work as an integral part of an
interdisciplinary team, ensuring
excellence in patient care, in an effort to achieve optimal clinical
outcomes through a seamless
of access and care.

Duties and Responsibilities of this Level
Assess patient's condition, locate appropriate treatment and resources,
ensure continuity of care
document treatment progression; provide individual counseling sessions
concerning rehabilitation
treatment and health maintenance.

Document interventions within medical record system(s) to collaborate
with health care providers
monitor treatment programs. Assess the overall health and health
education needs of the patient.
Review patient data related to disabilities or medical limitations and
maintain liaison with primary
care provider.

Participate in multi-disciplinary teams to promote a healthy context or
social environment;
and supporting local partnerships to broaden the local response to
health inequalities and
advocate for
patient acting in support providers.

Review and evaluate Admission, Discharge and Transfer (ADT) electronic
alerts, electronic medical
record notes or other patient trend data. Use communication systems
and telephone consultation
order to ascertain needs of identified patients.

Conduct community, telephone and practice encounters with patients and
other care management
team members to identify care plans, barriers and goals.

Follow-up with patients and providers on identified health care needs
and identify possible
to address those concerns and/or work with care management team to
address concerns in a
disciplinary method.

Facilitate and manage referrals from referral specialist, providers,
and other care management
staff to
ensure that identified red flags and healthcare needs of patients are

Provide individual consults to patients on health education issues.
Develop the health awareness of
individuals, as well as groups and organizations, empowering them to
make better health choices.

Provide specialized treatment, implementation of care plans, and
education to patients while
discretion and independent judgment; following established policies and

Assess the educational needs of the patient/caregiver as it relates to
the disease process,
in function, and assimilation back intothe home and community. Address
the total needs of the
individual: medical, psychosocial, behavioral, and spiritual.

Monitor access to care, services, and treatment including linkage to
the medical home.

Involve the patient and their support systems (i.e. caregiver, family,
etc.) in the decision-making
process. Use proven processes to measure patient’s understanding and
acceptance of the
plan(s), willingness to change, and support to maintain health behavior
change. Apply teaching
learning theories to assist patients and families with physical and
emotional impact of body
and chronic illness.

Document and communicate with all provider(s) and member(s) of the care
team as needed to
minimize fragmented care. This will include navigating transitions of
care – generally from hospital
home or community facilities.

Monitor quality and effectiveness of interventions to the population by
setting long term and/or
term specific, measurable goal(s).

Determine patient care plan using data from multiple sources such as
patient medical records,
and program metric reports to prioritize individuals for outreach,
education, and intervention.

Participate in quality/performance improvement projects and provide
presentations of outcomes in
various group settings, including provider and practice meetings, as

This position may require home visits however; position specific
details and duties are available

The work activity and patient acuity levels can create a stressful

Required Qualifications at this Level
Bachelor's degree in business, behavioral/social sciences, public
health orrelated population health

3 years of experience required

Degrees, Licensure, and/or Certification:

Knowledge, Skills, and Abilities:
The work activity and patient acuity levels can create a stressful
atmosphere, therefore individuals
successful in this job are:
Organized and motivated by a fast-paced environment
Able to manage multipletasks/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 population
based program metrics)

Distinguishing Characteristics of this Level
Additional job expectations include the ability to:
Maintain strict confidentiality
Promote programs and services to community
Build effective and trusting relationships with patient/peers.
Use motivational interviewing and active-listening skills when
assessing patient conditions,
and interests.
Use conflict-resolution skills when reaching consensus about plans of
care and treatment
Demonstrate confidence, compassion, political savvy, as well as
attention to detail to apply these
as decisions dictate.
Use data to analyze trends and to verify data.


Requisition Number

Position Title


Job Family Level

Full Time / Part Time

Regular / Temporary

Department Name

Minimum Qualifications
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.


Bachelor's degree in business, behavioral/social sciences, public health
or related population health field.


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 in
Social Work, Disease Management, and experience working directly with
Physicians and Advanced Practice Providers is strongly preferred.

Degrees, Licensures, Certifications