Case Manager RN
Company: MyMichigan Health
Location: Midland
Posted on: August 4, 2022
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Job Description:
Summary GENERAL SUMMARY Provides care management and care
coordination for adult and pediatric patients with complex illness
in the primary care setting under minimal supervision. Works with
both moderate and high risk patients to optimize control of chronic
conditions and prevent/minimize long term complications.
Coordinates care across settings and helps patient/families
understand health care options. In partnership with the primary
care practice leadership team, the Care Manager leads care
management within the team. The Case Manager (CM) accomplishes this
through process improvement, workflow redesign, providing
assistance with training, and delegating to other members of the
team. The CM serves in an expanded health care role to collaborate
with specialists, members of the health care team, and
patients/families ensuring the delivery of quality, efficient, and
cost-effective health care services. Assesses plans, implements,
coordinates, monitors and evaluates all options and services with
the goal of optimizing the patient's health status. Integrates
evidence-based clinical guidelines, preventive guidelines, and
protocols, in the development of individualized care plans that are
patient-centric, promoting quality and efficiency in the delivery
of health care. ESSENTIAL DUTIES AND RESPONSIBILITIES (25%)*
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. (20%)* 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. (20%)* Implements clinical
interventions and protocols based on risk stratification and
evidence-based clinical guidelines. (15%)* 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.
(10%)* Provides patient self-management support with a focus on
empowering the patient/family to build capacity for self- care.
(10%)* Implements systems of care that facilitate close monitoring
of high-risk patients to prevent and/or intervene early during
acute exacerbations. OTHER DUTIES AND RESPONSIBILITIES 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. Reviews the current literature
regarding effective engagement and communication strategies, care
management strategies, and behavior change strategies and
incorporates into clinical practice. REQUIRED EDUCATION,
EXPERIENCE, TRAINING AND SKILLS Associates Degree required,
Bachelors Degree in Nursing preferred Registered Nurse licensure
active in the State of Michigan required BLS required within 30
days of hire or transfer to position 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--both verbal and
written; dependable, self directed. PHYSICAL/MENTAL REQUIREMENTS
AND TYPICAL WORKING CONDITIONS Exposure to stressful situations,
including those involving public contact, as well as, trauma, grief
and death. Able to wear personal protective equipment that includes
latex materials or appropriate substitute if required for your
position. Is able to move freely about facility with or without an
assisted device and must be able to perform the functions of the
job as outlined in the job description. Overall vision and hearing
is necessary with or without assisted device(s). Frequently
required to sit/stand/walk for long periods of time. May require
frequent postural changes such as stooping, kneeling or crouching.
Some exposure to blood borne pathogens and other potentially
infectious material. Must follow MidMichigan Health bloodborne
pathogen and TB testing as required. Ability to handle multiple
tasks, get along with others, work independently, regular and
predictable attendance and ability to stay awake. Overall dexterity
is required including handling, reaching, grasping, fingering and
feeling. May require repetition of these movements on a regular to
frequent basis. Physical Demand Level: Light. Must be able to
occasionally (0-33% of the workday) lift or carry 11-20 lbs.,
frequently (34-66% of the workday) 10 lbs. and or
Walk/Stand/Push/Pull of Arm/Leg controls.
Keywords: MyMichigan Health, Midland , Case Manager RN, Healthcare , Midland, Michigan
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