SHS-RN CARE FACILITATOR - CLINICAL PROG

General Purpose of Job

As part of a larger population health strategy, the Care Facilitator will play an integral role in the larger ambulatory care management redesign for Sparrow Medical Group (SMG) practices, acting as the liaison to their locally assigned clinic(s).

Common Duties And Responsibilities

• Work with colleagues to set a standardized approach to patient outreach through both episodic and longitudinal care management.
• Work the Epic Registries to proactively identify high-risk patients with a focus on chronic disease management.
• Advance care planning, self-management training, and behavioral health support.

Essential Duties

• Supports the care and coverage needed in the clinic by working with colleagues.
• Provides self-management education and support to care team members, patients, and families.
• Edits and supports appropriate care team members in patient self-management support concepts and techniques.
• Aids patients and/or families in recognizing and prioritizing the problems that need to be addressed.
• Supports patients and/or families in coping with the disruptions and distress associated with managing their illness and empowering them to regain control of their life, carry on normal roles and activities, and manage the emotional impact of their illness.
• Solves problems with patients and their families to maximize their ability to follow preventive, remedial, and/or rehabilitative recommendations.
• Provides individual or group counseling/coaching as appropriate.
• Supports the office staff in providing care coordination.
• Maintains an effective professional working relationship with all patients, families, physicians/providers, and health care team members.
• Maintains an effective professional working relationship with specialists and facilities (including hospitals, home health care, and other ancillary providers) with which SMG physicians have ongoing relationships.
• Coordinates care with payer case managers for patients with complex or catastrophic conditions.
• Develops and recommends a plan, in conjunction with the patient, family, and health care team, which addresses the problems and needs identified in the assessment.
• Provides or arranges chronic disease education (as appropriate) for patients and families as needed.
• Provides consultation services for other department staff.
• Assists in developing a process to track care coordination activities.
• Assists in developing written procedures and/or guidelines on care coordination processes and trains appropriate care team members on the processes.
• Facilitates follow-up with patients discharged from the hospital or Emergency Department as needed to assure patients understand self-care and treatment expectations and are seen in primary care offices on a timely basis.
• Screens selected cases to identify needed services and interventions to deliver quality comprehensive care that addresses the patient’s full range of health care needs.
• Identifies issues, which may impact medical outcomes based on a comprehensive assessment that may include the patient’s medical condition, support systems, finances, living situation, housing, behavior, cognition, function and abilities, and the patient’s choices and preferences.
• Works with office staff as part of an interdisciplinary team, develops and implements a plan which addresses problems and needs identified in the assessment and ensures continuity of care by:
• Aiding patient and family with access to appropriate resources and services based on a thorough knowledge of community resources and eligibility requirements.
• Advocating on behalf of patients and their families with internal/external resources and payers for needed services, including negotiating with insurance companies for non-covered benefits.
• Communicates with patients, families, members of the health care team and others in a professional, diplomatic, and empathetic manner.
• Provides clear, concise, timely written documentation on the patient’s medical record and on departmental records.
• Collaborates with other members of the Sparrow Health System (SHS) departments to collect, analyze, and utilize data for quality/process improvement.
• Attends mandatory department and SHS meetings or training sessions.
• Provides or arranges education for patients, families, physicians, and other members of the health care team, to enhance patient care or improve department outcomes and operations.

Requirements

• Registered Nurse with a current Michigan license.
• Minimum of three years acute care clinical experience as a registered nurse.
• One year case management experience.
• Bachelor's degree in Nursing or health care related field OR must complete within 2 years of hire.
• Graduate degree in nursing or related health care field. Preferred.
• Demonstrates excellent clinical knowledge, skills, and judgment.
• Demonstrates excellent communication skills that include emotional intelligence, relationship building, negotiation, conflict resolution, persuasion, marketing, and patient advocacy.
• Demonstrates comprehensive case management assessment skills, with the ability to proactively and creatively problem solve.
• Demonstrates the ability to prioritize, organize, handle many tasks simultaneously, work autonomously, and manage time.
• Demonstrates the ability to work in stressful situations, manage conflict, and assume a leadership role.
• Completion of a nationally or internationally-accredited program in self management support concepts and techniques within 12 months of assuming this position if not completed prior to being hired.
• Ability to work in an EMR environment.
• Knowledge of case management that includes but is not limited to health care finance, hospital and community resources, discharge planning, utilization review, utilization management, ethical case management principles, and evidence-based practice concepts.
• Knowledge and demonstrated ability to collect, analyze, and utilize data for process improvement.
• National case management certification. Preferred.
• Experience with an EMR. Preferred.

Job Family

• Registered Nurses/Nursing Leadership

Requirements

• Shift: Days
• Facility: Sparrow Hospital