RN Care Manager: Chronic Disease & Care Coordination

Karmanos Cancer Institute; Michigan; Hybrid; USD 65,000 - 90,000; Full time

Job summary

McLaren Health Care is seeking a Registered Nurse Care Manager for the Clarkston Medical Group to partner with primary care teams in delivering comprehensive care management for patients with chronic, complex, and high-risk conditions. The role focuses on improving outcomes, closing gaps in care, and promoting adherence to each patient’s plan.

The RN will conduct assessments, identify barriers, develop individualized care plans, coordinate with care teams, and educate patients.

Qualifications

• Current unrestricted Registered Nurse license in the State of Michigan.
• Graduate of an accredited school of nursing.
• 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.

Responsibilities

• Identify, 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.

Skills

Care coordination

Chronic disease management

Patient education

Interdisciplinary collaboration

Care plan development

Education

Graduate of an accredited school of nursing

Tools

EMR systems

Job description

McLaren Health Care is seeking a Registered Nurse Care Manager for the Clarkston Medical Group to partner with primary care teams in delivering comprehensive care management for patients with chronic, complex, and high-risk conditions. The role focuses on improving outcomes, closing gaps in care, and promoting adherence to each patient’s plan.

The RN will conduct assessments, identify barriers, develop individualized care plans, coordinate with care teams, and educate patients.