Coordinator Care - Registered Nurse

About the Role

As an advocate for the patient, the RN care manager will assess, plan, implement, coordinate, monitor, and evaluate the options and services required to meet an individual’s health needs, using clinical and community resources to promote quality, cost-effective outcomes. Integrates evidence-based clinical guidelines, preventive guidelines, and protocols in the development of individualized care plans that are patient-centric. Provides targeted interventions to avoid hospitalization and emergency room visits.

Responsibilities

• Provides telephonic and face-to-face comprehensive assessment and care management services to patients as part of an interdisciplinary team.
• Uses multi-dimensional assessment skills, risk assessment, and screening tools to target high-risk and vulnerable populations.
• Assesses over time the health care, educational, and psychosocial needs of the patient/caregiver using standardized tools such as depression screening, functionality, and health risk assessment.
• Provides follow-up with patient/family during transitions between care settings.
• Completes timely post-hospital follow-up, including medication reconciliation, PCP or specialist follow-up appointments, symptom assessment, teaching warning signs, reviewing discharge instructions, coordinating care, and problem-solving barriers.
• Uses clinical judgment to determine the level of care and collaborates with the PCP, patient, and interdisciplinary team, including continuum of care settings and community resources.
• Develops a comprehensive individualized plan of care and targeted interventions, continually monitoring and revising the care plan as needed.
• Provides patient self-management support, empowering the patient/caregiver 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.
• Implements clinical interventions and protocols based on risk stratification and evidence-based clinical guidelines.
• Coordinates patient care through ongoing collaboration with PCP, patient/caregiver, McLaren Health Care, community agencies, health plans, and other disciplinary team members.
• Fosters a team approach, including the patient/caregiver as active members of the team, ensuring continuity of care beyond practice boundaries.
• Serves as a liaison to acute care hospitals, specialists, post-acute care services, and community services.
• Demonstrates excellent written, verbal, and listening communication skills, positive relationship-building skills, and critical analysis skills.
• Maintains required documentation of all care management activities.
• Works with MPP Medical leadership to evaluate processes, identify problems, and develop improvement strategies to enhance care management and the Patient-Centered Medical Home model.
• Reviews current literature on effective engagement, communication, care management, and behavior change strategies, incorporating them into clinical practice.
• Performs other duties as assigned to maintain efficient department and company operations.

Requirements

Required:

• RN with a valid unrestricted Michigan license.
• Three (3) years of clinical nursing experience serving chronically ill patients and extensive knowledge of issues associated with chronic care and geriatrics.

Preferred:

• RN, BSN.
• Three (3) years of experience in a health plan or Physician Organization environment with care coordination, care management, and/or population health.
• Telephonic care management experience.
• Home care and/or hospice experience.
• Complex Care Management course completion or CCM certification.

Schedule

Per Diem

Daily work times: 8:00 AM – 4:00 PM

Hours per pay period: 12

On-call: No

Weekends: No