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COMMUNITY HEALTH CASE MANAGER
Job Title: COMMUNITY HEALTH CASE MANAGER
Job Code: 3804
FLSA: E
Job Level: 75
Revised Date: 12/21/2022
Job Family: JF 32
Occupational Summary
The Community Health Care Manager will work with individuals in Durham who have limited connections to health care services to facilitate institutional transitions and strengthen connections to care, with the goal to decrease or avoid preventable adverse outcomes and improve quality of life. The Community Health Care Manager is expected to have an understanding of mental illness and addiction and be willing and ready to engage with clients who struggle with these issues at all levels.
Work Performed
Introduce program to patients and complete program enrollment and triage assessment
Conduct assessment of patient needs and appropriate next steps, including need for short-term medical respite care
Coordinate with agency referral staff, primary care provider, receiving agency, and other service providers as needed to facilitate effective and safe care transitions
Conduct transitional care follow up home visits or practice encounters according to established protocols
Develop overall care transition plan with patient, including primary care home, mental health and substance abuse services, assessment of disability and potential for employment, housing options, transportation, and social supports
Perform medication reconciliation and chronic disease education
Develop a Self-Care plan with each client that aims to foster an ownership of their long term health, and a working knowledge of how to work within the primary health care system
Provide education and training to inpatient nurses, social workers, discharge planners and other professionals to improve identification of patients within their organizations and systems and facilitate effective referrals
Lead monthly meetings with clinical and community care providers to review current cases and problem solve issues
Assist in the planning and creation of strategies to facilitate referrals, transitions, and communication among and between systems of care on behalf of patients
Build relationships with other community entities
Establish & maintain ongoing contact with service providers for clients
Develop community relationships to raise awareness of the transitions project
Participates in all relevant meetings, conferences and committees as assigned
Performs other related duties incidental to work described herein
Assist Clinical and Education / Research Director as needed
Required Qualifications at this Level
Education/Training
Minimum - RN with Bachelors in Nursing, Master in Nursing or Public Health preferred.
Experience
Four years of experience in a position involving direct patient contact, preferably working with the homeless and/or clients with medical, mental health, or substance abuse conditions. (Supervisory experience preferred; care coordination or case management experience preferred)
Skills
A general knowledge of Durham community and its resources is required. Interviewing, facilitation, and computer skills required. Ability to communicate effectively, verbally, and in writing to diverse populations including patients, staff, and general public required. Valid North Carolina driver's license with a good driving record and reliable vehicle is required
The intent of this job description is to provide a representative and level of the types of duties and responsibilities that will be required of positions given this title and shall not be construed as a declaration of the total of the specific duties and responsibilities of any particular position. Employees may be directed to perform job-related tasks other than those specifically presented in this description.
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.
