RN Care Manager: Chronic Care & Transitions

McLaren Health Care; Clarkston (MI); Presencial; USD 65 000 - 90 000; Tempo integral

Resumo da oferta

McLaren Health Care is seeking a Provider-Delivered Care Management (PDCM) Registered Nurse to partner with primary care teams, patients, and caregivers to deliver comprehensive care management for chronic and high-risk conditions. You will identify barriers, establish goals, and promote adherence to individual care plans, with a focus on improving outcomes and reducing avoidable utilizations.

The role may involve telephonic, electronic, virtual, or in-person care depending on patient need and

Qualificações

• Current unrestricted Registered Nurse license in the State of Michigan.
• Graduate of an accredited school of nursing.
• Associate degree in nursing required.
• Minimum of two years of clinical nursing experience preferred, particularly in primary care, ambulatory care, chronic disease management, care coordination, population health, home health, case management, or a related setting
• Current BLS certification as required by organizational policy.
• Experience caring for patients with chronic and complex medical conditions strongly preferred.
• Previous care-management, case-management, population-health, or transitional-care experience preferred.

Responsabilidades

• Identify, assess, enroll, and manage appropriate patients for PDCM, chronic care management, transitional care management, and other care-management services according to organizational requirements.
• Perform comprehensive nursing assessments to identify clinical needs, barriers to care, health literacy needs, psychosocial concerns, medication issues, healthcare utilization patterns, and opportunities for intervention.
• Collaborate with the patient, primary care provider, and interdisciplinary care team to develop, implement, monitor, and update an individualized patient-centered care plan.
• Establish meaningful and measurable goals with patients and caregivers and provide ongoing coaching and follow-up to promote progress toward those goals.
• Serve as a primary point of contact for patients participating in care management, helping facilitate timely communication between patients and their primary care providers when clinical changes or concerns arise.
• Recognize changes in patient condition, identify red-flag symptoms, and elevate concerns promptly to the appropriate provider or level of care in accordance with nursing scope of practice, clinical protocols, and organizational policy.
• Provide patient education regarding appropriate use of the healthcare system, including when symptoms may be managed through the primary care office and when evaluation by urgent care or an emergency department may be indicated.

Conhecimentos

Nursing

Care coordination

Chronic disease management

Patient education

Population health

Home health

Case management

Formação académica

Associate degree in nursing

RN license in Michigan

BLS certification

Descrição da oferta de emprego

McLaren Health Care is seeking a Provider-Delivered Care Management (PDCM) Registered Nurse to partner with primary care teams, patients, and caregivers to deliver comprehensive care management for chronic and high-risk conditions. You will identify barriers, establish goals, and promote adherence to individual care plans, with a focus on improving outcomes and reducing avoidable utilizations.

The role may involve telephonic, electronic, virtual, or in-person care depending on patient need and