Population Health Care Manager- QuEST

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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.

The Population Health Care Manager (PHCM) is responsible for providing clinical expertise to manage the healthcare needs of designated patient populations across the continuum of care. The primary objective of this role is to improve patient health outcomes, enhance access to care and community resources, reduce unnecessary healthcare utilization, and lower overall costs.

As an integral member of an interdisciplinary care team, the PHCM coordinates patient-centered care through seamless transitions, access management, and ongoing support. This role focuses on chronic disease management, preventive care, hospital follow-up, care coordination, and addressing medical, behavioral health, psychosocial, and social determinants of health needs across a variety of settings, including clinics, community locations, and patient homes.

Under the direction of the QuEST Manager, the PHCM also supports organizational quality initiatives through education, staff development, performance improvement, regulatory compliance, and clinical quality management activities.

• Manage a designated caseload and coordinate assessments, care plans, interventions, and follow-up activities for assigned patient populations.
• Conduct comprehensive evaluations of patient health status, social determinants of health, behavioral health needs, substance use concerns, economic factors, trauma history, and environmental influences.
• Develop and implement individualized, patient-centered care plans designed to address identified barriers and health concerns.
• Support chronic disease management and disease prevention initiatives.
• Coordinate transitional care management activities, including discharge planning and placement into the most appropriate level of care (e.g., skilled nursing facilities, assisted living, home health services, caregiver-supported home settings).
• Perform medication reconciliation and provide medication education and adherence support.
• Facilitate preventive care and quality gap closure initiatives.
• Connect patients with primary care providers, specialists, behavioral health services, social services, and community resources.

• Engage patients, caregivers, and support systems in care planning and decision-making processes.
• Utilize a whole-person approach that addresses medical, psychosocial, behavioral, spiritual, and social needs.
• Assess patient understanding, readiness for change, and ability to maintain health behavior modifications.
• Apply evidence-based teaching and learning principles to promote self-management and patient empowerment.
• Educate patients and families regarding chronic illnesses, treatment plans, and the physical and emotional impacts of health conditions.

• Collaborate with physicians, primary care providers, nurses, specialists, psychiatrists, social workers, discharge planners, and community partners to ensure coordinated care delivery.
• Facilitate communication among interdisciplinary team members to reduce fragmented care and optimize clinical outcomes.
• Coordinate transitions of care across healthcare settings and community-based services.
• Develop and maintain positive working relationships with internal and external stakeholders.

• Provide in-person, telephonic, and virtual outreach to patients, providers, and community partners.
• Conduct visits in patient homes, clinics, community organizations, and other approved settings when clinically appropriate.
• Ensure services are culturally responsive and sensitive to diverse patient populations.
• Identify and address barriers to care through community resource engagement and partnership development.

• Maintain accurate, timely, and complete documentation of all care management activities within Maestro and other designated systems.
• Monitor patient outcomes and intervention effectiveness using measurable short-term and long-term goals.
• Participate in quality assurance, performance improvement, and population health initiatives.
• Analyze data from medical records, claims,…