Population Health Care Manager – Care Transition

Duke Careers

. Provide clinical expertise, support, and guidance for care transitions of patients discharged from Duke University Health System and other identified hospitals and facilities .

Posted 11/2/2026full-timeRemote • North Carolina • United StatesMid-LevelSeniorWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in clinical assessments, care planning, and disease management while effectively coordinating care transitions for patients. Proficient in electronic documentation and fostering interdisciplinary communication to enhance patient outcomes.

Highest-signal resume keywords

Clinical AssessmentsCare PlanningDisease ManagementElectronic Documentation in MaestroInterdisciplinary Coordination

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Care CoordinationPatient EducationReferral ManagementSymptom ManagementDisease Assessment

Soft Skills

CommunicationRelationship BuildingDecision-MakingPatient Engagement

Tools & Technologies

MaestroElectronic Health Records

Certifications & Qualifications

ACM CertificationCCM CertificationRN LicensureLicensed Clinical Social WorkerLicensed Professional CounselorLicensed Addiction Specialist

Industry Keywords

Transitional CareCase ManagementHealthcare ResourcesCommunity HealthPatient Support

About the role

Key responsibilities & impact

Provide clinical expertise, support, and guidance for care transitions of patients discharged from Duke University Health System and other identified hospitals and facilities
Support inpatient case management with discharge disposition functions, including FL2s and referrals to skilled nursing facilities and other facilities
Support discharged patients telephonically through proactive transitional care calls and inbound assistance calls
Perform disease and symptom management, disease assessment, care plan development and facilitation, and referrals to appropriate levels of care
Coordinate and facilitate assessments, care plans, and interventions addressing patients’ medical, social, physical, mental health, substance use, trauma, economic, and educational needs
Provide individual treatment and targeted interventions using patient medical records, claims, and program metric reports
Connect patients with primary care providers and other healthcare resources
Involve patients and support systems in decision-making and promote self-management
Measure patient understanding, acceptance, willingness to change, and support for maintaining health behavior change
Apply teaching and learning theories to assist patients and families with chronic illness and physical and emotional changes
Electronically document all activity in Maestro and other relevant systems
Coordinate with providers and care team members to minimize fragmented care and facilitate transitions between hospitals, homes, and community facilities
Facilitate interdisciplinary communication with specialists, PCPs, RNs, psychiatrists, discharge planners, case managers, social workers, physicians, and community resources
Conduct on-site, community, and telephonic outreach to patients, providers, and community stakeholders
Provide feedback to team leadership, management, and executive leadership to improve payer negotiations, care management, and care gaps
Develop and maintain positive relationships with internal and external Duke Health System customers

Requirements

What you’ll need

Bachelor’s degree in a clinical field such as Nursing, Counseling, Social Work, Therapy, Allied Health, or community health related fields
3 years of clinical experience required
Current license in at least one of the following: current or compact RN licensure in North Carolina; current licensure as a licensed clinical social worker by the NC Social Work Certification and Licensure Board; current licensure as a Licensed Professional Counselor by the state of NC; or current licensure as a Licensed Addiction Specialist by the state of North Carolina
Requires ACM or CCM certification within 3 years of hire date
Ability to perform clinical assessments, care planning, disease and symptom management, patient education, referrals, and care coordination
Ability to document electronically in Maestro and other relevant documentation systems
Ability to coordinate with interdisciplinary providers, patients, caregivers, families, hospitals, primary care practices, public health and social service departments, mental health agencies, and community resources

Benefits

Comp & perks

Equal Opportunity Employer committed to providing employment opportunity without regard to age, color, disability, gender, gender expression, gender identity, genetic information, national origin, race, religion, sex, sexual orientation, or military status
Community built on collaboration, innovation, creativity, belonging, diversity, and inclusion
Reasonable accommodation information and provision available for essential physical job functions