02/13/2023
Seeking a Registered Nurse (RN) Care Manager in Monroe, Michigan; for a full-time, direct patient contact position with an opportunity for some telephonic/telemedicine interactions.
The RN Care Manager works in collaboration and continuous partnership with chronically ill or high-risk patients and their family/caregiver(s), specialty providers and staff, and community resources in a team approach. The goals are:
1. Promotion of timely access to appropriate care
2. Increase of preventive care services
3. Decrease of emergency room utilization and hospital readmissions
4. Increase of comprehension through culturally and linguistically appropriate education
5. Creation and promotion of adherence to a care plan, developed in coordination with the patient, primary care provider, and family/caregiver(s)
6. Increase of continuity of care by managing relationships with tertiary care providers, transitions-in-care, and referrals.
7. Increase patient’s ability for self-management and shared decision-making
8. Providing medication reconciliation
9. Connecting patients to relevant community resources, with the goal of enhancing patient health and well-being, increasing patient satisfaction, and reducing health care costs
10. Aligning resources with patient and population needs
11. Assisting with advance directives, palliative care, hospice and end of life care coordination
12. Engaging in quality improvement initiatives
ESSENTIAL DUTIES AND RESPONSIBILITIES
A typical day for the Care Manager will include conducting one-on-one extended patient meetings which are approximately. 30-60 minutes long, and spending time on follow-up with patients, family/caregiver(s), providers, and community resources via phone and other secure methods of communication.
Care Manager:
1. Identifies patients appropriate for services per P*P referral, risk stratification, patient attribution lists and other strategies, including patients with repeated health and/or social crises
2. Serves as the contact point, advocate, and informational resource for patients, care team, family/caregiver(s), payers, and community resources
3. Coordinates with the rest of the care team, complete comprehensive and structured assessment for all patients engaged in services (including but not limited to health assessment, functional status, self-management knowledge, values, and preferences
4. Assess patients’ unmet health and social needs
5. Develops a comprehensive care plan with the patient, family/caregiver(s)
6. Monitors adherence to care plans, evaluates effectiveness, monitors patient progress in a timely manner, and facilitate changes as needed
7. Facilitates patient access to appropriate medical, behavioral health and specialty providers
8. Educates patient and family/caregiver(s) about relevant community resources
9. Conducts regular in-person team huddles with P*P to evaluate, monitor and review progress of current patient care plans
10. Identifies treatment opportunities and practice level interventions to close gaps in care across all populations
11. Targets interventions to avoid hospitalizations and emergency visits
EDUCATION / EXPERIENCE
• Licensed and credentialed Registered Nurse (RN) in State of Michigan,
• 1+ years experience in clinical or community resource settings; care coordination and/or case management experience is desirable
• Knowledge of connections to community health care and social welfare resources
• Knowledge of chronic conditions, evidence-based guidelines, prevention, wellness, health risk assessment, and patient education
• Excellent assessment and triage skills
• Highly organized with ability to keep accurate notes and records
• Demonstrates excellent communication skills-both verbal and written
• Meets productivity standards; completes work in timely manner
• Strong computer literacy including knowledge Microsoft Word, Excel, Power Point, and Outlook are required
