Registered Nurse - Coordinator Care

Karmanos Cancer Institute; Michigan; Hybrid; USD 68,000 - 90,000; Full time

Benefits offered by this job

Full-time schedule

Hours 8:00am-4:30pm

No on-call requirement

Job summary

McLaren Health Care is seeking an RN Care Manager to assess, plan, implement, coordinate, monitor and evaluate patient care. You will work within an interdisciplinary team to apply guidelines and develop individualized care plans focused on reducing hospitalizations and improving outcomes.

Requires an active Michigan RN license and at least 3 years of chronic care nursing experience; BSN preferred. Schedule: Full-time, 8:00am-4:30pm; on-site role with no on-call duties.

Qualifications

• RN with a valid unrestricted Michigan license.
• Three (3) years clinical nursing experience serving chronically ill patients.
• Three (3) years experience in care coordination, care management, or population health preferred.
• Telephonic care management experience preferred.
• Home care and/or hospice experience preferred.
• CCM certification or Complex Care Management course is a plus.

Responsibilities

• Provides telephonic and face-to-face comprehensive assessment and care management services to patients as part of an interdisciplinary team.
• Uses risk assessment and screening tools to target high risk and vulnerable populations.
• Develops comprehensive individualized plans of care and monitors responses.
• Coordinates care with PCP, specialists, and community resources to prevent hospitalizations.
• Ensures documentation of all care management activities and maintains care continuity.

Skills

Care coordination

Care management

Telephonic care management

Patient advocacy

Education

RN license

BSN preferred

Job description

The McLaren system includes 12 hospitals across the state, ambulatory surgery centers, imaging centers, a 730-member employed primary and specialty care physician network, commercial and Medicaid HMOs covering more than 242,000 Michigan lives, home health, infusion and hospice providers, pharmacy services, a clinical laboratory network, and a wholly owned medical malpractice insurance company. McLaren operates Michigan’s largest network of cancer centers and providers, anchored by the Karmanos Cancer Institute, a National Cancer Institute-designated comprehensive cancer center. McLaren has 20,000 full-, part-time and contracted employees and more than 93,000 network providers throughout Michigan.

As an advocate for the patient, the RN care manager will assess, plan, implement, coordinate, monitor, and evaluate the options and services required to meet an individual’s health needs, using clinical and community resources to promote quality, cost effective outcomes. Integrates evidenced based clinical guidelines, preventive guidelines, and protocols, in the development of individualized care plans that are patient centric. Provides targeted interventions to avoid hospitalization and emergency room visits.

Essential Functions and Responsibilities:

1. Provides telephonic and face-to-face comprehensive assessment and care management services to patients as part of an interdisciplinary team.

2. Uses multi-dimensional assessment skills, risk assessment and screening tools to target high risk and vulnerable populations.

3. Assesses over time the health care, educational, and psychosocial needs of the patient/caregiver. Uses standardized assessment tools such as depression screening, functionality, and health risk assessment.

4. Provides follow up with patient/family when patient transitions from one setting to another. Completes timely post-hospital follow up: Medication reconciliation, PCP or specialist follow-up appointment, assess symptoms, teach warning signs, review discharge instructions, coordination of care, and problem solve barriers.

5. Uses clinical judgment to determine level of care and collaborates with the PCP, patient and interdisciplinary team, including continuum of care settings and community.

6. 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.

7. Provides patient self-management support with a focus on empowering the patient/caregiver to build capacity for self-care.

8. Implements systems of care that facilitate close monitoring of high-risk patients to prevent and/or intervene early during acute exacerbations.

9. Implements clinical interventions and protocols based on risk stratification and evidenced-based clinical guidelines.

10. Coordinates patient care through ongoing collaboration with PCP, patient/caregiver, McLaren Health Care, community agencies, health plans, and other disciplinary team members.

11. Fosters a team approach and includes patient/caregiver as active members of the team.

12. Takes the lead in ensuring the continuity of care which extends beyond the practice boundaries.

13. Serves as liaison to acute care hospitals, specialists, post-acute care services and community services.

14. Demonstrates excellent written, verbal and listening communication skills, positive relationship building skills, and critical analysis skills.

15. Maintains required documentation of all care management activities.

16. Works with MPP Medical 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.

17. Reviews the current literature regarding effective engagement and communication strategies, care management strategies, and behavior change strategies and incorporates them into clinical practice.

18. Other duties as assigned or when necessary to maintain efficient operations of the department and the Company as a whole.

Qualifications:

Required:

• RN with a valid unrestricted Michigan license.
• Three (3) years clinical nursing experience serving chronically ill patients and extensive knowledge of issues associated with chronic care and geriatrics.

Preferred:

• RN, BSN.
• Three (3) years experience in a health plan or Physician Organization environment with care coordination, care management, and/or population health.
• Telephonic care management experience.
• Home care and/or hospice experience.
• Complex Care Management course completion or CCM.

Additional Information

• Schedule: Full-time
• Daily Work Times: 8:00am-4:30pm
• On Call: No

McLaren Health Care is an Equal Opportunity Employer. Qualified applicants will receive consideration for employment without regard to race, color, religion, sexual orientation, gender identification, age, sex, marital status, national origin, disability, genetic information, height or weight, protected veteran or other classification protected by law.

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McLaren Health Care is an Equal Opportunity Employer. Qualified applicants will receive consideration for employmentwithout regard to race, color, religion, sexual orientation, gender identification, age, sex, marital status,national origin, disability, genetic information, height or weight, protected veteran or other classificationprotected by law.