RN Care Management
Company: MyMichigan Health
Posted on: August 4, 2022
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
- 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
- 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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