RN Care Manager

$32.00 - $38.00 hourly
  • Silver Pine Medical Group
  • 53950 Van Dyke, Shelby Twp, MI 48316
  • Sep 20, 2022
Full time Health Care

Job Description

The RRN Care Manager provides care management and care coordination for adult and pediatric patients with moderate to complex illness in the primary care setting, under minimal supervision. Serves in an expanded health care role to collaborate with specialists, members of the health care team, and patients/families to ensure the delivery of quality, efficient, and cost-effective health care services. Assesses care plans, implements, coordinates, monitors and evaluates all options and services with the goal of optimizing the patient’s health and emotional status. Integrates evidence-based clinical guidelines, preventive guidelines, and protocols, in the development of individualized care plans that are patient-centric, promoting quality and efficiency in the delivery of health care.

Manage and actively follow a caseload of patients. Provides targeted interventions to avoid hospitalization and emergency room visits. Coordinates care across settings and helps patient/families understand health care options.

Job Duties

· Identifies high-risk population within practice per PCP referral, risk stratification, and predetermined patient groups

· Follows patient health, emotional status, and needs of the patient/family using standard assessment tools

· Collaborates with PCP, patient, and members of the health care team

· Develops a comprehensive individualized plan of care and targeted interventions and continually monitors patient/family

· Provides patient self-management support with a focus on empowering the patient/family to build capacity for self- care.

· Implement systems of care to facilitate close monitoring of high-risk patients

· Implements clinical interventions and protocols based on risk stratification and evidence-based clinical guidelines.

· Coordinates patient care through ongoing collaboration with PCP, patient/family, community, and other members of the health care team.

· Provides follow-up with patient/family when patient transitions from one setting to another in a timely manner

· Works with practice leadership to identify patients who would benefit from Care Management support.

· Demonstrates excellent written, and communication skills, positive relationship building skills, and critical analysis skills.

· Maintains required documentation for all care management activities.

Qualifications and Education

  • Current Michigan Registered Nurse, Nurse Practitioner, Physician Assistant or Master of Social Work License
  • Three years of experience with adult medicine and pediatric patients in primary care/ambulatory care, home health agency, skilled nursing facility, or hospital medical-surgical setting, within the past five years
  • Knowledge of chronic conditions, evidence-based guidelines, prevention, wellness, risk assessment, and patient education
  • Critical thinking skills and ability to manage complex clinical issues utilizing assessment skills and protocols
  • Excellent assessment / triage skills with the ability to implement evidence base interventions and protocols
  • Demonstrates excellent communication--both verbal and written
  • Ability to affect change, work as a productive and effective team member, and adapt to changing needs/priorities
  • Time management, priority setting, work delegation and work organization.
  • General computer knowledge and capability to use computer