TEL. Careers
Registered Nurse Care Manager
Job Description
This is an opening for Registered Nurse (RN) Care Manager in Monroe, MI which is a full-time, direct contact position with a limited opportunity for some telephonic/telemedicine interactions.
The RN Care Manager works in collaboration and continuous partnership with chronically ill or high-risk patients and their family/caregiver(s), specialty providers and staff, and community resources in a team approach. The goals are:
- Promotion of timely access to appropriate care
- Increase of preventive care services
- Decrease of emergency room utilization and hospital readmissions
- Increase of comprehension through culturally and linguistically appropriate education
- Creation and promotion of adherence to a care plan, developed in coordination with the patient, primary care provider, and family/caregiver(s)
- Increase of continuity of care by managing relationships with tertiary care providers, transitions-in-care, and referrals.
- Increase patient’s ability for self-management and shared decision-making
- Providing medication reconciliation
- Connecting patients to relevant community resources, with the goal of enhancing patient health and well-being, increasing patient satisfaction, and reducing health care costs
- Aligning resources with patient and population needs
- Assisting with advance directives, palliative care, hospice and end of life care coordination
- Engaging in quality improvement initiatives
Essential Functions
A typical day for the Care Manager will include conducting one-on-one extended patient meetings which are approximately. 30-60 minutes long, and spending time on follow-up with patients, family/caregiver(s), providers, and community resources via phone and other secure methods of communication.
Care Manager:
- Identifies patients appropriate for services per PCP referral, risk stratification, patient attribution lists and other strategies, including patients with repeated health and/or social crises
- Serves as the contact point, advocate, and informational resource for patients, care team, family/caregiver(s), payers, and community resources
- Coordinates with the rest of the care team, complete comprehensive and structured assessment for all patients engaged in services (including but not limited to health assessment, functional status, self-management knowledge, values, and preferences
- Assess patients’ unmet health and social needs
- Develops a comprehensive care plan with the patient, family/caregiver(s) and providers which may include an emergency plan, health management plan, healthcare summary, and ongoing action plan, as appropriate
- Monitors adherence to care plans, evaluates effectiveness, monitors patient progress in a timely manner, and facilitate changes as needed
- Creates ongoing processes for patient and family/caregiver(s) to determine and request the level of care coordination support they desire at any given point in time
- Facilitates patient access to appropriate medical, behavioral health and specialty providers
- Educates patient and family/caregiver(s) about relevant community resources
- Facilitates and attends meetings between patient, family/caregiver(s), care team, payers, and community resources, as needed
- Cultivates and supports primary care and specialty provider co-management with timely communication, inquiry, follow-up, and integration of information into the care plan regarding transitions-in-care and referrals
- Conducts regular in-person team huddles with PCP to evaluate, monitor and review progress of current patient care plans
- Engages in quality improvement activities utilizing the Model for Improvement
- Monitors patient utilization via various electronic tools and payer reports
- Identifies treatment opportunities and practice level interventions to close gaps in care across all populations
- Targets interventions to avoid hospitalizations and emergency visits
- Focuses on adult and pediatric patients with high complexity, high cost, and/or high utilizers of the healthcare system
- Ensures payer’s initiative and goals are assessed and tracked
- Conducts patient outreach in a proactive and routine manner
Knowledge/Skill/Abilities
- Demonstrates a positive attitude and respectful, professional customer service
- Proactively acts as patient advocate, responding with empathy and respect to resolve patient and family concerns, and recognizes opportunities for improvement to meeting patient concerns
- Proactively continues to educate self on providing quality care and improving professional skills
Required Education
Required Experience
- Knowledge of connections to community health care and social welfare resources
- Knowledge of chronic conditions, evidence-based guidelines, prevention, wellness, health risk assessment, and patient education
- Knowledge of Quality Improvement techniques such as the Model for Improvement
- Excellent assessment and triage skills
- Evidence of essential leadership, communication, education, and counseling skills
- Highly organized with ability to keep accurate notes and records
- Experience with health IT systems and report generation is desirable
- Demonstrates excellent communication skills-both verbal and written
- Excellent interpersonal and facilitation skills
- Ability to affect change, work as a productive and effective team member, to be flexible, and adapt to needs/priorities
- Displays willingness to make decisions; exhibits sound and accurate judgment; supports and explains reasoning for decisions
- Meets productivity standards; completes work in timely manner
- Is a team player and works well with other members of the organization
- Able to maintain pleasant working relationships
- Strong computer literacy including knowledge Microsoft Word, Excel, Power Point, and Outlook are required
Preferred Experience
- 1+ years experience in clinical or community resource settings; care coordination and/or case management experience is desirable
Preferred Licensure/Certification
- Licensed and credentialed Registered Nurse (RN) in State of Michigan
Job Type: Full-time
