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Population Health Leader - General Internal Medicine

Job ID: 5772
Location: Chapel Hill, NC
Facility/Division: UNC Faculty Physicians
Status: Full Time
Shift: Day Job

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Job Description


Population Health Leader

Population Health Leader works as part of a multidisciplinary ambulatory care team to serve patients with complex social, environmental, and mental health needs that prevent them from reaching their health goals.

The Population Health Leader will: provide complex care management services for patients from across the clinic; and will provide diagnostic assessment and short term behavioral counseling within dedicated clinic hours.

Duties and Responsibilities – Population Health Leader will:

·Support Social Work Team Lead in oversight of and response to requests for Care Management services handled by Population Health Specialist/Care Management Intake Coordinator.

·Provide direct complex care management as indicated or directed to assist patients with multiple chronic illnesses through assessment, counseling, care management, psychoeducation, advocacy and linkage to long-term community and home based services, advocacy, and facilitation of continuity of care and coordination of services.

·Conduct biopsychosocial assessment including social determinants of health, with patients to assess and determine community supports (food, transportation, mental health programs, substance abuse programs, etc.) available to them in efforts to improve their quality of life.

·Conduct assessment to determine need for medical treatment, and/or need for higher level or continuity mental health, substance abuse, and psychiatric services.

·Provide care management support to bridge patients to appropriate outside support services.

·Use brief solution focused interventions along with psychoeducation and motivational interviewing with patients to assist in meeting patient stated self-care management and mental health goals.

·Provide clinical diagnostic assessments of counseling patients and short term evidenced based Problem Solving Treatment to address program scope clinical issues that impact health and self-care management; refer or bridge to higher level, specialized or continuity services as indicated.

·Work in collaboration with physicians, advanced practice providers, nurses, other LCSWs, psychiatrists, pharmacists, and other care partners to serve Care Management and Counseling patients.

·Provide support for Hospital Follow Up Clinic to reduce hospital readmissions by providing patients with connections to social, emotional, and financial supports in their community, and will complete biopsychosocial assessments to determine barriers to care and risk for readmission.

·Support clinic with 30 day transitions workflow including running reports, distributing patients among team members and conducting follow up for select patients thirty days post discharge.

·Assist physicians and clinic staff in working with at-risk in clinic patients or callers.

·Connect patients with appropriate emergency mental health services and when necessary help to facilitate hospitalization to ensure patient safety.

·Assist in maintaining updated electronic medical record patient Resource Smartphrase Lists.

·Maintain timely, professional documentation and contribute to program reporting of work.

    ·Other duties and responsibilities as needed and directed

    Licensed Clinical Social Worker preferred. Prefer experience with complex care management and resources, work with end-of-life planning, work with vulnerable populations, experience in short term goal-focused behavioral counseling for primary care. Bilingual ability with Spanish and English speaking preferred. 

    Other Information

    Other information:
    Education Requirements:
    ● Master's degree in Social Work (MSW) from a program accredited by the Council on Social Work Education or graduation from a state accredited school of professional nursing.
    Licensure/Certification Requirements:
    ● No licensure or certification required.
    Professional Experience Requirements:
    ● Five (5) years of experience in a health care setting.
    Knowledge/Skills/and Abilities Requirements:

    Job Details

    Legal Employer: STATE

    Entity: UNC Faculty Physicians

    Organization Unit: Division Of General Medicine 

    Work Type: Full Time

    Standard Hours Per Week: 40.00

    Work Schedule: Day Job

    Location of Job: US:NC:Chapel Hill

    Exempt From Overtime: Exempt: Yes

    This is a State position employed by UNC Health Care System.
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    Diversity Statement

    The UNC Health System and the UNC School of Medicine are committed to valuing all people throughout our organization, regardless of background, lifestyle, and culture. A diverse and inclusive work environment for staff and culturally appropriate care for our patients, are essential to fulfilling our UNC Health vision of improving the health of all North Carolinians.

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    UNC Health is an equal opportunity employer. As such, UNC Health offers equal employment opportunities to applicants and employees without regard to race, color, religion, sex, national origin, age, genetic information, disability, sexual orientation, gender identity or political affiliation.

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