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Role Description

As an advocate for the patient, the RN care manager will assess, plan, implement, coordinate, monitor, and evaluate the options and services required to meet an individual’s health needs, using clinical and community resources to promote quality, cost effective outcomes.

Integrates evidenced based clinical guidelines, preventive guidelines, and protocols, in the development of individualized care plans that are patient centric.

Provides targeted interventions to avoid hospitalization and emergency room visits.

• Provides telephonic and face-to-face comprehensive assessment and care management services to patients as part of an interdisciplinary team.
• Uses multi-dimensional assessment skills, risk assessment and screening tools to target high risk and vulnerable populations.
• Assesses over time the health care, educational, and psychosocial needs of the patient/caregiver using standardized assessment tools such as depression screening, functionality, and health risk assessment.
• Provides follow up with patient/family when patient transitions from one setting to another.
• Completes timely post-hospital follow up: Medication reconciliation, PCP or specialist follow-up appointment, assess symptoms, teach warning signs, review discharge instructions, coordination of care, and problem solve barriers.
• Uses clinical judgment to determine level of care and collaborates with the PCP, patient and interdisciplinary team, including continuum of care settings and community.

Qualifications

• RN with a valid unrestricted Michigan license.
• Three (3) years clinical nursing experience serving chronically ill patients and extensive knowledge of issues associated with chronic care and geriatrics.

Requirements

• RN, BSN preferred.
• Three (3) years experience in a health plan or Physician Organization environment with care coordination, care management, and/or population health.
• Telephonic care management experience.
• Home care and/or hospice experience.
• Complex Care Management course completion or CCM.