REGISTERED NURSE (Primary Care - RN Complex Care Navigator)

Michigan Medicine; Ann Arbor (MI); Hybrid; USD 60,000 - 93,000; Full time

Benefits offered by this job

Excellent medical, dental, and vision

Retirement savings match

Generous PTO

Job summary

Michigan Medicine seeks a dedicated RN Complex Care Manager to identify high-risk patients, assess needs, and develop comprehensive care plans. You will collaborate with physicians, nurses, social workers, and community resources to coordinate inpatient and ambulatory care transitions and to improve health outcomes.

Responsibilities include ongoing care coordination, patient education, and post-discharge follow-up, with emphasis on self-management support and evidence-based protocols.

Qualifications

• Current Michigan license as a Registered Nurse.
• Two years of experience working with complex adult and pediatric patients.
• Two years of experience in case management, IP or ambulatory care.
• Knowledge and experience with management of chronic conditions, evidence based guidelines, prevention, wellness, health risk assessment, and patient education.
• Ability to manage complex clinical issues utilizing assessment skills and protocols.
• Excellent assessment and triage skills.

Responsibilities

• Identifies the targeted high-risk population within practice site(s) and risk stratification.
• Assesses health, educational, and psychosocial needs over time using standardized tools.
• Develops an individualized plan of care with targeted interventions.
• Provides self-management support to empower patients and families.
• Coordinates care across providers, hospitals, and post-acute services.
• Monitors progress and revises the care plan as needed.
• Maintains thorough documentation for all care activities.
• Participates in process improvement to enhance care model delivery.

Skills

Interpersonal skills

Autonomy

Influence & negotiation

Adaptability

Leadership

Relationship building

Education

BSN preferred

Case Manager certification (preferred)

Job description

Mission Statement

Michigan Medicine improves the health of patients, populations and communities through excellence in education, patient care, community service, research and technology development, and through leadership activities in Michigan, nationally and internationally. Our mission is guided by our Strategic Principles and has three critical components; patient care, education and research that together enhance our contribution to society.

RN Complex Care Manager (Care Navigator)

• Identifies the targeted high- risk population within practice site(s), risk stratification, and patient lists.
• Assesses over time the health care, educational, and psychosocial needs of the patient/family. Uses standardized assessment tools such as SDOH, pain scale, depression screening, functionality, and health risk assessment.
• Collaborates with Provider and Interdisciplinary 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.
• 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.
• Implements clinical interventions and protocols based on risk stratification and evidence-based clinical guidelines.
• Coordinates patient care through ongoing collaboration with providers, patient/family, community, and other members of the health care team. Fosters an interdisciplinary 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.
• Provides follow-up with patient/family when patient transitions from one setting to another. Completes timely post-discharge calls: Medication reconciliation, PCP or specialist follow-up appointment, assess symptoms, assess psycho-social status, teach warning signs, review discharge instructions, coordination of care, review goals of care discussion and problem solve barriers.
• Provides telephone triage and advice, patient education, and direct patient care and hand-offs.
• Provides functional supervision of assistive personnel.
• Demonstrates excellent written, verbal, and listening communication skills, positive relationship building skills, and critical analysis skills.
• Maintains required documentation for all care activities.
• Works with practice and PO/PHO 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.

Skills And Abilities

• Demonstrates customer focused interpersonal skills to interact in an effective manner with practitioners, the interdisciplinary health care team, community agencies, patients, and families with diverse opinions, values, and religious and cultural ideals.
• Demonstrates ability to work autonomously and be directly accountable for practice.
• Demonstrates ability to influence and negotiate individual and group decision-making.
• Demonstrates ability to function effectively in a fluid, dynamic, and rapidly changing environment.
• Demonstrates leadership qualities including time management, verbal and written communication skills, listening skills, problem solving, critical thinking, analysis skills and decision-making, priority setting, work delegation, and work organization.
• Demonstrates ability to develop positive, longitudinal relationships and set appropriate boundaries with patients/families.

Expectations Of The Position

• Demonstrates excellent communication--both verbal and written
• Excellent interpersonal and facilitation skills
• Ability to affect change, work as a productive and effective team member, and adapt to changing needs/priorities
• Time management, priority setting, work delegation and work organization. General computer knowledge and capability to use computer
• Demonstrated excellent attendance and punctuality

Required Qualifications

• Current Michigan license as a Registered Nurse
• Two years of experience working with complex adult and pediatric patients
• Two years of experience in case management, IP or ambulatory care.
• Knowledge and experience with management of chronic conditions, evidence based guidelines, prevention, wellness, health risk assessment, and patient education
• Ability to manage complex clinical issues utilizing assessment skills and protocols
• Excellent assessment and triage skills.

NOTE: Required qualifications must be met by the candidate in order to be interviewed and considered for the position.

RESUME REQUIRED (for Both Internal & External Applicants)

You must attach a complete and accurate resume to be fully considered for this position.

Desired Qualifications

• BSN preferred
• Demonstrated partnership and leadership with members of the health care team in current chronic care initiatives as validated by performance evaluations and references.
• Completion of self-management support training.
• Certification as a Case Manager by the Case Management Society of America/AAACN and/or CHPN (Hospice/Palliative Care Nursing Certification within 3 years of hire
• Ambulatory Care Experience

Nursing Specific Info

Salary & Nursing Framework Level

This UMPNC RN posting is posted as Nursing Framework LEVEL C.

Actual Nursing Framework LEVEL and salary will be determined at time of hire.

Nursing Framework levels range from Level A to Level F.

Required qualifications must be met by the candidate in order to be interviewed and considered for the position.

Posting may be filled after the initial 5-day posting period.

Applicants who have left the UMPNC bargaining unit must include on their resume dates of past employment including months and years of service along with effort.

Positions less than 20 hours/week may be combined.

Michigan Medicine Overview

Michigan Medicine is one of the largest health care complexes in the world and has been the site of many groundbreaking medical and technological advancements since the opening of the U-M Medical School in 1850. Michigan medicine is comprised of over 26,000 employees and our vision is to attract, inspire, and develop outstanding people in medicine, sciences, and healthcare to become one of the world's most distinguished academic health systems. In some way, great or small, every person here helps to advance this world-class institution. Work at Michigan Medicine and become a victor for the greater good.

What Benefits can you Look Forward to?

Nursing at Michigan offers a competitive salary with excellent benefits!

Hourly range for Registered Nurses

$43.46- $67.40/ hour

• Evening Shift Differential-$3.00 / hour
• Night Shift Differential- $4.00 / hour
• Day Shift Weekend Differential- $2.90 / hour
• Evening Shift Weekend Differential- $5.90 / hour
• Night Shift Weekend Differential- $6.90 / hour
• Charge Nurse Differential- $1.00 / hour

The Benefit Package Includes

• Excellent medical, dental and vision coverage
• 2:1 Match on retirement savings and immediate vesting
• Generous Paid Time Off Allowances
• Robust Tuition and Certification support programs
• Large offering of no cost CEs and professional development for advancement

Modes of Work

Positions that are eligible for hybrid or mobile/remote work mode are at the discretion of the hiring department. Work agreements are reviewed annually at a minimum and are subject to change at any time, and for any reason, throughout the course of employment. Learn more about the work modes.

Work Schedule

• Hours/Week: 40
• Shift/Hours/Days: Day Shift; Mon-Fri, (hours are variable).
• Hours may be variable (nontraditional including weekends/holidays) based on clinic/patient/volume needs due to patient and volume demands.
• Location: Primary Care clinic
• Hours may be variable (nontraditional) based on clinic needs.
• NOTE: This is a multi-unit position.

Note: All new employees will be expected to float to a designated unit(s) in times of low census.

Union Affiliation

This position is covered under the collective bargaining agreement between the U-M and the Michigan Nurses Association and the U-M Professional Nurse Council union, which contains and settles all matters with respect to wages, benefits, hours and other terms and conditions of employment.

Background Screening

Michigan Medicine conducts background screening and pre-employment drug testing on job candidates upon acceptance of a contingent job offer and may use a third party administrator to conduct background screenings. Background screenings are performed in compliance with the Fair Credit Report Act. Pre-employment drug testing applies to all selected candidates, including new or additional faculty and staff appointments, as well as transfers from other U-M campuses.

U-M EEO Statement

The University of Michigan is an Equal Opportunity Employer. We are committed to providing an environment of mutual respect where equal employment opportunities are available to all applicants, including protected veterans and individuals with disabilities.