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RN Care Management

Company: MyMichigan Health
Location: Midland
Posted on: August 4, 2022

Job Description:

Summary At MidMichigan Health, our purpose is Creating Healthy Communities - Together. We invite you to apply and join our team! ESSENTIAL DUTIES AND RESPONSIBILITIES

Collaborates with primary care provider (PCP), patient, and members of the health care team, including continuum of care settings and community. Responsible for developing a comprehensive individualized plan of care and targeted interventions. Continually monitors patient/family response to plan of care, and revises the care plan as indicated. Identifies the targeted high-risk population within practice site(s) per PCP referral, risk stratification, and patient lists. Includes patients with repeated social and/or health crises. Implements clinical interventions and protocols based on risk stratification and evidence-based clinical guidelines. Assesses over time the health care, educational, and psycho-social needs of the patient/family. Uses standardized assessment tools such as depression screening, functionality, and health risk assessment. Provides patient self-management support with a focus on empowering the patient/family 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. Fosters a team approach and includes patient/family as active members of the team. Takes the lead in ensuring the continuity of care which extends beyond the practice boundaries. Serves as liaison to acute care hospitals, specialists, and post-acute care services. Completes timely post-hospital follow-up, such as, medication reconciliation, Primary Care Provider (PCP) or specialist follow-up appointment, assess symptoms, teach warning signs, review discharge instructions, coordination of care, and problem solve barriers. Possesses effective leadership skills to direct the team and the patient/family. Strong interpersonal skills, both written and verbal needed to communicate successfully with individuals and groups and interact with people at all levels. Maintains required documentation for all care management activities. Works with practice and PO leadership to continuously evaluate process, identify problems, and propose/develop process improvement strategies to enhance care management and Patient Centered Medical Home delivery of care model. REQUIRED CERTIFICATIONS AND LINCENSURE RN-Registered Nurse Equivalent Experience - Knowledge of nursing technique as normally acquired through the completion of a registered nursing program and hold a license in the State of Michigan. REQUIRED EDUCATION AND SKILL SET Education: Associates Degree Preferred Education: Bachelor's Degree or higher in a clinical field.
  • Case management experience is preferred.
  • Three years of experience with adult medicine/pediatric patients in primary care/ambulatory care, home health agency, skilled nursing facility, or hospital medical-surgical setting, within the past five years.
  • Knowledge of chronic conditions, evidence based guidelines, prevention, wellness, health risk assessment, and patient education.
  • Critical thinking and problem solving skills and ability to analyze complex data sets.
  • Ability to manage complex clinical issues utilizing assessment skills and protocols
  • Excellent assessment and triage skills.
  • Ability to implement evidence base interventions and protocols for chronic conditions Demonstrates excellent communication--verbal and written; dependable, self-directed.

Keywords: MyMichigan Health, Midland , RN Care Management, Healthcare , Midland, Michigan

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