Care Manager - RN- CIN at Southwest Days 40hrs/wk

umhealthwest•Wyoming, MI

About The Position

Under the direction of the Director, the Care Manager - RN provides care management services to adult and pediatric patients in an ambulatory setting. The Care Manager - RN performs clinical assessments and therapeutic interventions for complex patients with multiple chronic conditions and comorbidities. In addition, this position serves as community resource expert and care coordinator across the continuum of care. Furthermore, the Care Manager - RN optimizes care by engaging patients in the principles of self-management, goal setting and continuous improvement. This integral role expands primary care’s scope of practice by focusing on patient’s biopsychosocial needs to ensure the delivery of comprehensive, efficient and quality care.

Requirements

Possesses excellent time management, work delegation and organization skills.
Exhibits creative problem solving and critical thinking skills
Excellent written and verbal communication skills.
Comprehensive knowledge of community resources.
Knowledge of chronic medical and mental health conditions.
Ability to triage and manage complex clinical issues utilizing assessment skills and protocols.
Ability to work independently as well as in a team environment.
Ability to adapt to changes in health care with the goal of improving quality, efficiency and cost effectiveness of care.
Knowledge of electronic medical record documentation.
Current State of Michigan License (unrestricted) as a Registered Nurse (RN)
Two (2) years of clinical nursing or RN experience required with three (3+) or more years of experience preferred.

Nice To Haves

Bachelor's in Nursing preferred
Case Management Certified preferred

Responsibilities

Receives and acts on referrals for moderate and complex patients through risk stratification, registries and provider referrals
Assesses patients’ mental health and biopsychosocial needs through standardized assessments
Recommends treatment plans based on evidence based guidelines
Educates patients on preventive health, chronic illness and recommended treatments
Provides care coordination and follow-up for chronic medical conditions across the continuum of care
Follows patients longitudinally to evaluate treatment goals
Advocates for patients and family while maintaining professional boundaries
Educates and supports patients in the use of self-management techniques and develops action plans to encourage self-care
Facilitates transitions of care for admitted and discharged patients from the hospital or emergency department to ensure continuity of care
Consults with members of the care team throughout the continuum on treatment plans and follow-up care
Participates in process improvement activities to enhance primary care services and workflow
Offers group education classes for patients with chronic conditions