RN Care Manager: Patient-Centric Care & Coordination

McLaren Health Care; Lansing (MI); On-site; USD 55,000 - 74,000; Full time

Job summary

McLaren Health Care in Michigan is seeking an RN Care Manager to assess, plan, implement, coordinate and evaluate patient care within an interdisciplinary team. The role emphasizes patient-centered care and outcome improvement.

The position focuses on telephonic and in-person care management, using evidence-based guidelines to prevent hospitalizations and optimize transitions of care for chronically ill patients.

Qualifications

• 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.

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.
• Provides follow up with patient/family when patient transitions from one setting to another, including post-hospital follow up and discharge instruction review.
• Uses clinical judgment to determine level of care and collaborates with PCP, patient and interdisciplinary team.
• Develops a comprehensive individualized plan of care and targeted interventions and revises as needed.
• Provides patient self-management support to empower patients and caregivers.
• Implements systems of care to monitor high-risk patients and prevent acute exacerbations.
• Coordinates patient care through ongoing collaboration with PCP, patient/caregiver, McLaren Health Care, community agencies, health plans, and other team members.
• Maintains documentation of all care management activities.

Skills

Communication

Care coordination

Education

BSN

Job description

McLaren Health Care in Michigan is seeking an RN Care Manager to assess, plan, implement, coordinate and evaluate patient care within an interdisciplinary team. The role emphasizes patient-centered care and outcome improvement.

The position focuses on telephonic and in-person care management, using evidence-based guidelines to prevent hospitalizations and optimize transitions of care for chronically ill patients.