RN Care Manager

About the role

Welcome to Cherry Health - video about Cherry Health. This is a full time, benefit eligible position typically working Monday - Friday 8am-5pm onsite at our Cherry Street Health Center. This role will travel to other Cherry Health medical sites around West Michigan.

Responsibilities

• Identify and outreach to patients due for Medicare AWVs utilizing targeted patient lists.
• Assess over time the healthcare, educational, and psychosocial needs of the patient/family using standardized assessment tools such as depression screening, functionality, and health risk assessments.
• Collaborate with primary care providers, patients, and members of the healthcare team, including continuum of care settings and the community, to develop a comprehensive individualized care plan and targeted interventions.
• Provide patient self-management support, focusing on empowering the patient/family to build capacity for self-care.
• Act as the lead in ensuring continuity of care that extends beyond the practice boundaries.
• Serve as a liaison to acute care hospitals, specialists, and post-acute care services.
• Complete and maintain required documentation of timely post-hospital visit follow-up, medication reconciliation, primary care provider or specialist follow-up appointments, teaching warning signs, reviewing discharge instructions, coordinating care, and problem-solving barriers.
• Collaborate with Cherry Health’s leadership to continuously evaluate processes, identify problems, and propose/develop process improvement strategies to enhance care management and Patient-Centered Medical Home delivery of care models.
• Understand and adhere to Cherry Health’s compliance standards as they appear in Cherry Health’s Corporate Compliance Policy, Code of Conduct, and Conflict of Interest Policy.
• Keep abreast of all pertinent federal, state, and Cherry Health regulations, laws, and policies as they currently exist and as they change or are modified.
• Other duties as assigned.

Requirements

• Basic Life Support/CPR certification according to requirements of license and/or certification.
• Demonstrate customer-focused interpersonal skills to interact effectively with practitioners, the interdisciplinary healthcare team, community agencies, patients, and families with diverse opinions, values, and cultural/religious ideals.
• Demonstrate excellent written, verbal, and listening communication skills, positive relationship-building skills, and critical analysis skills.
• Demonstrate the ability to work autonomously and be directly accountable for practice.
• Demonstrate the ability to influence and negotiate individual and group decision-making.
• Demonstrate leadership qualities, including time management, verbal and written communication skills, listening skills, problem-solving, critical thinking, analysis skills, decision-making, priority setting, work delegation, and work organization.
• Demonstrate the ability to develop positive, longitudinal relationships and set appropriate boundaries with patients/families.
• Knowledge of chronic conditions, evidence-based guidelines, prevention, wellness, health risk assessments, and patient education.
• Critical thinking skills and the ability to analyze complex data sets.
• Able to manage complex clinical issues using assessment skills and protocols.
• Excellent assessment and triage skills.
• Able to implement evidence-based interventions and protocols for chronic conditions.
• General computer knowledge and the ability to use a computer effectively.

Qualifications

• Degree as RN (Associates, Bachelors, or Masters).
• Licensure with the State of Michigan as a Registered Nurse required.
• Completion of self-management support training preferred.
• Three years of nursing experience with adult medicine patients in primary care/ambulatory care, home health agency, skilled nursing facility, or hospital medical-surgical settings within the past five years, or an equivalent combination of education and experience sufficient to successfully perform the essential duties of the job.

Skills

• Basic Life Support/CPR certification according to requirements of license and/or certification.
• Demonstrate customer-focused interpersonal skills to interact effectively with practitioners, the interdisciplinary healthcare team, community agencies, patients, and families with diverse opinions, values, and cultural/religious ideals.
• Demonstrate excellent written, verbal, and listening communication skills, positive relationship-building skills, and critical analysis skills.
• Demonstrate the ability to work autonomously and be directly accountable for practice.
• Demonstrate the ability to influence and negotiate individual and group decision-making.
• Demonstrate leadership qualities, including time management, verbal and written communication skills, listening skills, problem-solving, critical thinking, analysis skills, decision-making, priority setting, work delegation, and work organization.
• Demonstrate the ability to develop positive, longitudinal relationships and set appropriate boundaries with patients/families.
• Knowledge of chronic conditions, evidence-based guidelines, prevention, wellness, health risk assessments, and patient education.
• Critical thinking skills and the ability to analyze complex data sets.
• Able to manage complex clinical issues using assessment skills and protocols.
• Excellent assessment and triage skills.
• Able to implement evidence-based interventions and protocols for chronic conditions.
• General computer knowledge and the ability to use a computer effectively.

Benefits

• Loan repayment through the NHSC and Michigan State Loan Repayment Program for select roles.
• Medical, Dental and Vision Insurance for you and your family.
• Generous Paid Time Off benefit – 4 weeks per year for full time.
• Paid holidays - 8 full day paid holidays (Including Black Friday!) and 2 half day paid holidays!
• 403(b) Retirement Savings Plan with generous employer match - $ for $ match up to 5% MET and MESP.
• 529 Savings Plans.
• Pet Insurance!
• Employee Assistance Program.