Population Health Specialist- AMH+

Duke Connected Care is a community-based, physician-led network that includes doctors, hospitals, and other healthcare providers working together to deliver high-quality care to Medicare Fee-for-Service patients in Durham and surrounding areas. Overview The Population Health Specialist develops, implements, and evaluates comprehensive patient care plans to improve management of complex, chronic health conditions. The role supports clinical expertise for specific patient populations, facilitates interdisciplinary collaboration, and focuses on smooth transitions in care for patients, physicians, families, and the community. Responsibilities Develop, implement, and evaluate comprehensive patient care plans. Conduct disease‑management assessments and define care plan facilitation. Coordinate referrals and ensure continuity of care across settings. Provide individual counseling and health‑education sessions for patients and caregivers. Document interventions in electronic medical records and collaborate with other health‑care providers. Monitor treatment progress, assess outcomes, and adjust plans based on data analysis. Participate in quality and performance‑improvement projects and present findings to supervisory teams. Perform home visits as required by the position. Skills and Abilities Organized with strong time‑management skills, able to work effectively in a fast‑paced environment. Proficient in using computer software, electronic medical records, and managing data files. Capable of managing multiple tasks or projects simultaneously. Excellent written and verbal communication, including motivational interviewing and active listening. Maintains strict confidentiality and adheres to data privacy requirements. Demonstrates empathy, compassion, and ability to build trust with patients and families. Skilled in data analysis to identify trends and inform decision‑making. Minimum Qualifications Bachelor’s degree in business, behavioral/social sciences, public health, or a related population‑health field. Three years of experience in a population‑health or related field, with strong preference for experience in disease management, social work, or direct collaboration with physicians and advanced practice providers. 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. Duke aspires to create a community built on collaboration, innovation, creativity, and belonging. All members of the community have a responsibility to uphold these values. Read more about Duke’s commitment to affirmative action and nondiscrimination at hr.duke.edu/eeo . #J-18808-Ljbffr