RN Care Manager - Care Management at Home Program

Trinity Health • Grand Rapids, MI

3d • Onsite

About The Position

The RN Care Manager is a professional nurse who collaborates with physicians, facilities, health care team members and patient/families to manage chronic conditions/complex illness and coordinate care for specific patient populations across the continuum and between care settings as an important member of the Patient Centered Medical Home team. The CM @ Home Team Care Manager provides supplemental Care Management services to our highest risk patients both in the patient's home and telephonically. The CM @ Home team works in collaboration with our Trinity Health Medical Group and affiliate office care teams. This position is responsible for engaging patients in Care Management with the goal(s) of successful self-management, improving safety and quality of life in the community setting, decreasing inappropriate utilization of the ED and hospital resources, providing supplemental home-based Care Management services in partnership with ambulatory care teams to guide patients toward their healthcare goals and objectives, reinforcing the plan of care, providing connections to medical and social resources that will address barriers to patients success in self-management, coordinating patient care with the primary care provider and specialty care providers as clinically appropriate, and providing Transitional Care Management to CHF patients discharged from the inpatient setting as well as frequent Emergency Room use.

Requirements

• Graduate of an accredited school of nursing.
• Bachelor of Science degree in Nursing required.
• Current licensure to practice nursing in Michigan.
• Three years of clinical experience in nursing required.

Nice To Haves

• Master's Degree in Nursing (or actively pursuing Master's Degree in Nursing) preferred.
• Recent case management experience preferred.
• One year of experience in Case Management preferred.

Responsibilities

• Participate and engage their patients in the assessment, planning, monitoring and evaluation of the ongoing care for chronic condition/complex illness management.
• Establish plans of care including patient education, self-management, care coordination, and coordinating resources for effective, efficient and appropriate patient care.
• Provide ongoing monitoring and evaluation of patient outcomes.
• Perform population health management, which includes risk stratification to identify high and rising-risk patients.
• Provide care coordination and management, patient engagement, and addressing SIOH needs in proactive efforts to improve outcomes, reduce cost, and improve health equity.
• Assist patients in optimizing their health status; providing interventions designed to avoid hospitalization and emergency room visits.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level