CARE MANAGEMENT SPECIALIST RN

Covenant HealthCare; Saginaw, Northern (MI, KY); Hybrid; USD 70,000 - 90,000; Full time

Benefits offered by this job

Medical, dental, and vision coverage

Retirement match

Paid time off

Wellness programs

Tuition reimbursement

Job summary

Covenant HealthCare is seeking a Care Management Specialist RN to advocate for patients, coordinate care, and guide families through disease self-management in the primary care setting.

Your role includes leading care management for medically complex children and adults, collaborating with the Care Connect team, and ensuring high-quality, cost-effective care under Covenant HealthCare standards.

Qualifications

• RN with a bachelor's degree in healthcare field or pursuing within 6 months with 3 years acute care experience.
• Must have a current Registered Nurse (RN) license to practice in the State of Michigan.
• EPIC experience preferred.
• Three (3) years of experience with adult medicine and pediatric patients in primary care/ambulatory care settings preferred.
• Experience with patients with co-occurring mental health, substance use, and physical health issues.

Responsibilities

• Coordinate care through ongoing collaboration with PCP, patient/family, community, and health care team.
• Lead continuity of care beyond practice boundaries; monitor and revise care plans as needed.
• Address social determinants of care needs (access to health care, education, psychosocial needs).
• Manage a caseload of approximately 85 to 120 patients.
• Foster a team approach including patient/family as active members.
• Serve as liaison to hospitals, specialists, and post-acute services.
• Develop comprehensive individualized plans of care to promote health and wellbeing.
• Identify high-risk patients using standardized assessments.
• Provide self-management support and empower families.
• Document all activities in EMR and track outcomes in registry.
• Conduct TOC calls within 2 business days of discharge.
• May cover multiple offices; participate in continuing education opportunities.

Skills

Psychopharmacology basics

Ethical practice

Behavioral health

Assessment & triage

Autonomous practice

Interpersonal skills

Epic experience

Microsoft Excel

Microsoft Word

Education

Bachelor's degree in nursing

RN license in Michigan

Tools

EPIC EMR

Job description

Overview

The Care Management Specialist RN is passionate about advocating for patients' needs and helping them navigate the healthcare system and engages with assigned patient population in the primary care setting to promote optimal health and deliver direct nursing care in accordance with established policies, procedures and protocols of the healthcare organization. This position will lead care management/coordination for medically complex children and adults and act as a resource, and guides families and patients through disease self-management, and serves in an expanded health care role collaborating with inpatient care management specialists, Care Connect team, patients and families to ensure delivery of quality, efficient, and cost-effective health care.

The Care Management Specialist RN demonstrates excellent customer service performance in attitude and actions that are at all times consistent with the standards contained in the Vision, Mission and Values of Covenant Healthcare and the commitment to Extraordinary Care for Every Generation.

Responsibilities

• Coordinates patient care through ongoing collaboration with PCP, patient/family, community, and other members of the health care team.
• When appropriate, takes the lead in ensuring continuity of care extends beyond the practice boundaries. Continually monitors patient/family response to plan of care and revises the care plan as indicated.
• Addresses and refers for social determinants of care needs, i.e. access to health care, educational, and psychosocial needs of the patient/family.
• Actively manages a caseload of approximately 85 to 120 patients.
• Fosters a team approach and includes patient/family as active members of the team.
• Serves as liaison to acute care hospitals, specialists, and post-acute care services.
• Responsible for developing a comprehensive individualized plan of care to promote overall health and wellbeing. Continually monitors patient/family response to plan of care and revises the care plan as indicated.
• Identify high-risk patients and use standardized assessment tools such as depression screenings, functionality and health risk assessments.
• Provides patient self-management support with a focus on empowering the patient/family to build capacity for self- care.
• Maintains required documentation for all Care Management activities including patient progress and treatment recommendations in EMR that can be shared with treating providers and codes appropriately for services provided. Track patients follow up and clinical outcomes using a registry, within EMR or spreadsheet.
• Responsible for transition of care (TOC) calls, within 2 business days of discharge, from an acute or semi-acute setting to home. TOC includes medication reconciliation, ensuring PCP or specialist follow-up appointments are arranged, assessing symptoms, teaching warning signs, reviewing discharge instructions, coordination of care, and problem-solving barriers.
• May be responsible for covering multiple offices.
• Participate in required continuing education opportunities.

Qualifications

EDUCATION/EXPERIENCE REQUIREMENTS:

• RN with a bachelors degree in healthcare related field or will be working toward completion of bachelors degree within 6 months and three (3) years acute care experience.OR RN with a Minimum of an Associates degree in nursing and a current license in the State of Michigan, five (5) years in an acute care setting or case management experience.
• Must have a current Registered Nurse (RN) license to practice in the State of Michigan.
• EPIC experience preferred.
• Three (3) years of experience with adult medicine and pediatric patients in primary care/ambulatory care, home health agency, skilled nursing facility, or hospital medical-surgical setting within the past five (5) years preferred.
• Experience working with patients who have co-occurring mental health, substance abuse, and physical health issues. Experience working with community agencies and health care providers.

KNOWLEDGE/SKILLS/ABILITIES

• Basic knowledge of psychopharmacology for common mental health disorders.
• Commitment to ethical practice of social work principles (patient self-determination, privacy, dignity, cultural sensitivity).
• Knowledge of behavioral health conditions, evidence-based guidelines, mental health risk assessment, and patient education preferred.
• Ability to manage complex mental health issues utilizing assessment skills and protocols.
• Excellent assessment, triage and critical thinking skills.
• Ability to implement evidence base interventions and protocols for mental health conditions.
• Ability to travel to work in the physician offices, attend meetings and conferences as needed.
• Demonstrates customer focused interpersonal skills, and the ability with the understanding of cultural diversity to interact in an effective manner with practitioners, patients, and families.
• Demonstrates ability to work autonomously and be directly accountable for practice.
• Excellent computer knowledge and capability to use computer; i.e. Microsoft Word, Excel. Epic experience preferred.
• Demonstrates ability to develop positive, longitudinal relationships and set appropriate boundaries with patients/families.

WORKING CONDITIONS/ PHYSICAL DEMANDS

• Ability to maintain regular, punctual attendance consistent with the ADA, FMLA and other federal, state and local standards.
• Constant Sitting, near vison, finger dexterity, talking, hearing, tasting/smelling.
• Frequent Depth perception.
• Frequent lifting up to 10 lbs.
• Occasional Standing, walking, lifting/carrying, pushing/pulling, stooping, kneeling, crouching, squatting, crawling, far vision.
• Occasional lifting up to 50 lbs.

Why Work at Covenant HealthCare

At Covenant HealthCare, we are united by a shared mission of providing Extraordinary Care for Every Generation. We foster a culture built on teamwork, excellence, accountability, respect, customer service, and enthusiasm, where every employee plays an important role in delivering patient-centered care and making a difference in our community.

Our benefits include:

• Comprehensive medical, dental, and vision coverage
• Retirement plans with employer match
• Paid time off to support work-life balance
• Employee wellness programs and mental health support
• Tuition reimbursement, university discounts, and professional development opportunities