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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


  • 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

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