Care Manager - Geriatric Primary Care Schoolcraft

Trinity Health

4d•Onsite

About The Position

Make a Meaningful Impact Beyond the Bedside! Trinity Health IHA Medical Group is seeking a compassionate and patient-focused Care Manager to join our outpatient care team. In this role, you'll help patients navigate their healthcare journey through clinical triage, care coordination, patient education, and ongoing support that improves outcomes and enhances the patient experience.

Requirements

Graduate of an accredited Registered Nurse program.
Valid, unrestricted RN license in the State of Michigan.
Valid CPR certification.
3-5 years of clinical experience with oncology patients in primary care/ambulatory care, home health agency, skilled nursing facility, or hospital, within the past five years: knowledge of chronic conditions, evidence-based guidelines, prevention, wellness, health risk assessment, and patient education.

Nice To Haves

CCM/CCP certification.

Responsibilities

Collaborates with members of the health care team and patient to ensure the delivery of quality, efficient, patient centered, and cost effective healthcare services.
Assists patients who are at risk for developing chronic conditions to minimize these risks by providing self-management support and patient education; Empowers patients to manage their health
Provides targeted interventions to avoid hospitalization and emergency room visits; in specialty population the care manager ensures proper triaging of the patient and appropriate delivery of care in accordance with established protocols.
Assesses, plans, implements, monitors, and evaluates delivery of individualized patient care with the goal of optimizing the patient’s health status.
Participates in the outreach and engagement of patients that are hospitalized to assist with the transition of care and provides support and education to avoid further readmissions.
Coordinates the care and services of selected member populations across the continuum of care, promotes effective utilization and monitoring of health care resources, and assumes a collaborative role with all members of the healthcare team to achieve optimal clinical and resources outcomes.