Case Manager RN - Pine Avenue (Alma)

MyMichigan Health • Midland, MI

76d

About The Position

This position will work 3 days onsite in the office and 2 days remote. Provides care management and care coordination for adult and pediatric patients with complex illness in the primary care setting under minimal supervision. Works with both moderate and high risk patients to optimize control of chronic conditions and prevent/minimize long term complications. Coordinates care across settings and helps patient/families understand health care options. In partnership with the primary care practice leadership team, the Care Manager leads care management within the team. The Case Manager (CM) accomplishes this through process improvement, workflow redesign, providing assistance with training, and delegating to other members of the team. The CM serves in an expanded health care role to collaborate with specialists, members of the health care team, and patients/families ensuring the delivery of quality, efficient, and cost-effective health care services. Assesses plans, implements, coordinates, monitors and evaluates all options and services with the goal of optimizing the patients health 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.

Requirements

• RN: Registered Nurse MI
• Education: Associates: BSN is preferred.
• 2 years of case management experience is preferred.
• Three years of experience with adult medicine/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, health risk assessment, and patient education.
• Health plan/Payer experience is preferred.
• Critical thinking and problem solving skills and ability to analyze complex data sets.
• Ability to manage complex clinical issues utilizing assessment skills and protocols.
• Excellent assessment and triage skills.
• Ability to implement evidence base interventions and protocols for chronic conditions.
• Demonstrates excellent communication--both verbal and written; dependable, self directed.
• Experience with managed care data systems and reporting.
• Must be able to type documentation concurrently during conversations.
• Proficiency in various word processing, spreadsheet, graphic and database programs, including Microsoft Word, Excel, Access, PowerPoint, Outlook, etc.

Responsibilities

• Collaborates with primary care provider (PCP), patient, and members of the health care team, including continuum of care settings and community. Responsible for developing a comprehensive individualized plan of care and targeted interventions. Continually monitors patient/family response to plan of care, and revises the care plan as indicated.
• Identifies the targeted high-risk population within practice site(s) per PCP referral, risk stratification, and patient lists. Includes patients with repeated social and/or health crises.
• Implements clinical interventions and protocols based on risk stratification and evidence-based clinical guidelines.
• Assesses over time the health care, educational, and psycho-social needs of the patient/family. Uses standardized assessment tools such as depression screening, functionality, and health risk assessment.
• Provides patient self-management support with a focus on empowering the patient/family to build capacity for self-care.
• Implements systems of care that facilitate close monitoring of high-risk patients to prevent and/or intervene early during acute exacerbations.

What This Job Offers

• Education Level: Associate degree
• Number of Employees: 5,001-10,000 employees