RN Care Navigator for Chronic Care & Transitions

University of Michigan Health-West; Wyoming (MI); On-site; USD 42,000 - 60,000; Part time

Job summary

University of Michigan Health-West is seeking a Care Manager - RN to provide care management services to both adult and pediatric patients in an ambulatory setting. The role includes triage, coordination across the continuum of care and patient self-management support, with a focus on chronic conditions and biopsychosocial needs.

This 0.6 FTE position works days (Mon/Tue/Thu), with no on-call and no weekend requirements, emphasizing collaborative practice and process improvement to enhance

Qualifications

• RN license in Michigan (unrestricted) required.
• Bachelor's in Nursing preferred.
• Case management certification preferred.
• Two years of clinical RN experience required; three+ years preferred.

Responsibilities

• Receives and acts on referrals for moderate and complex patients through risk stratification, registries and provider referrals.
• Assesses patients’ mental health and biopsychosocial needs through standardized assessments.
• Recommends treatment plans based on evidence-based guidelines.
• Educates patients on preventive health, chronic illness and recommended treatments.
• Provides care coordination and follow-up for chronic medical conditions across the continuum of care.
• Follows patients longitudinally to evaluate treatment goals.
• Advocates for patients and family while maintaining professional boundaries.
• Educates and supports patients in self-management and action plans.
• Facilitates transitions of care from hospital or ED to ensure continuity of care.
• Consults with care team on treatment plans and follow-up care.
• Participates in process improvement activities to enhance primary care services.
• Offers group education classes for patients with chronic conditions.

Skills

Time management

Problem solving

Communication

Community resources

Chronic illness knowledge

Triage & complex care

Independent & team work

Adapt to change in health care

EMR documentation

Education

RN license (Michigan)

Bachelor's in Nursing preferred

Case Management Certification preferred

Job description

University of Michigan Health-West is seeking a Care Manager - RN to provide care management services to both adult and pediatric patients in an ambulatory setting. The role includes triage, coordination across the continuum of care and patient self-management support, with a focus on chronic conditions and biopsychosocial needs.

This 0.6 FTE position works days (Mon/Tue/Thu), with no on-call and no weekend requirements, emphasizing collaborative practice and process improvement to enhance