RN Care Manager: Chronic Care Navigator

McLaren Health Care; Flint (MI); On-site; USD 65,000 - 95,000; Full time

Job summary

McLaren Health Care in Flint, Michigan, seeks an RN care manager to assess, plan, implement, coordinate, monitor, and evaluate care, using clinical and community resources to promote quality, cost‑effective outcomes and patient‑centered plans.

You will work with an interdisciplinary team, perform risk assessments, support transitions from hospital to home, and empower patients and families to manage health needs, aiming to prevent hospitalizations and ER visits while applying evidence‑based

Qualifications

• RN with a valid unrestricted Michigan license.
• Three (3) years clinical nursing experience serving chronically ill patients.
• Preferred experience in care coordination, care management, and population health.

Responsibilities

• Provides telephonic and face-to-face comprehensive assessment and care management services to patients as part of an interdisciplinary team.
• Uses multi-dimensional assessment skills, risk assessment and screening tools to target high risk and vulnerable populations.
• Assesses over time the health care, educational, and psychosocial needs of the patient/caregiver.
• Completes timely post-hospital follow up: medication reconciliation, follow-up appointments, assess symptoms, teach warning signs, review discharge instructions, and coordinate care.
• Collaborates with PCP and team to determine level of care across continuum and community settings.
• Develops comprehensive individualized care plans and revises them as needed.
• Provides patient self-management support to empower self-care.
• Implements systems of care to monitor high-risk patients and intervene early.
• Implements clinical interventions based on risk stratification and guidelines.
• Coordinates care with McLaren Health Care, community agencies, and health plans.
• Fosters a team approach with patient/caregiver as active members.
• Ensures continuity of care beyond practice boundaries.
• Serves as liaison to hospitals, specialists, post-acute care, and community services.
• Maintains documentation of all care management activities.
• Collaborates with leadership to improve care management processes.
• Reviews literature on engagement and communication strategies and applies them in practice.
• Other duties as assigned to maintain department operations.

Skills

Care coordination

Clinical nursing

Telephonic care management

Education

RN with Michigan license

BSN preferred

Job description

McLaren Health Care in Flint, Michigan, seeks an RN care manager to assess, plan, implement, coordinate, monitor, and evaluate care, using clinical and community resources to promote quality, cost‑effective outcomes and patient‑centered plans.

You will work with an interdisciplinary team, perform risk assessments, support transitions from hospital to home, and empower patients and families to manage health needs, aiming to prevent hospitalizations and ER visits while applying evidence‑based