CARE MANAGEMENT SPECIALIST RN

The Care Management Specialist RN is passionate about advocating for patients' needs and helping them navigate the healthcare system and engages with assigned patient population in the primary care setting to promote optimal health and deliver direct nursing care in accordance with established policies, procedures and protocols of the healthcare organization. This position will lead care management/coordination for medically complex children and adults and act as a resource, and guides families and patients through disease self-management, and serves in an expanded health care role collaborating with inpatient care management specialists, Care Connect team, patients and families to ensure delivery of quality, efficient, and cost-effective health care.

The Care Management Specialist RN demonstrates excellent customer service performance in attitude and actions that are at all times consistent with the standards contained in the Vision, Mission and Values of Covenant Healthcare and the commitment to Extraordinary Care for Every Generation.

• Coordinates patient care through ongoing collaboration with PCP, patient/family, community, and other members of the health care team.
• When appropriate, takes the lead in ensuring continuity of care extends beyond the practice boundaries. Continually monitors patient/family response to plan of care and revises the care plan as indicated.
• Addresses and refers for social determinants of care needs, i.e. access to health care, educational, and psychosocial needs of the patient/family.
• Actively manages a caseload of approximately 85 to 120 patients.
• Fosters a team approach and includes patient/family as active members of the team.
• Serves as liaison to acute care hospitals, specialists, and post-acute care services.
• Responsible for developing a comprehensive individualized plan of care to promote overall health and wellbeing. Continually monitors patient/family response to plan of care and revises the care plan as indicated.
• Identify high-risk patients and use standardized assessment tools such as depression screenings, functionality and health risk assessments.
• Provides patient self-management support with a focus on empowering the patient/family to build capacity for self- care.
• Maintains required documentation for all Care Management activities including patient progress and treatment recommendations in EMR that can be shared with treating providers and codes appropriately for services provided. Track patients follow up and clinical outcomes using a registry, within EMR or spreadsheet.
• Responsible for transition of care (TOC) calls, within 2 business days of discharge, from an acute or semi-acute setting to home. TOC includes medication reconciliation, ensuring PCP or specialist follow-up appointments are arranged, assessing symptoms, teaching warning signs, reviewing discharge instructions, coordination of care, and problem-solving barriers.
• May be responsible for covering multiple offices.
• Participate in required continuing education opportunities.

EDUCATION/EXPERIENCE REQUIREMENTS:

• RN with a bachelors degree in healthcare related field or will be working toward completion of bachelors degree within 6 months and three (3) years acute care experience. OR RN with a Minimum of an Associates degree in nursing and a current license in the State of Michigan, five (5) years in an acute care setting or case management experience.

• Must have a current Registered Nurse (RN) license to practice in the State of Michigan.
• EPIC experience preferred.
• Three (3) years of experience with adult medicine and pediatric patients in primary care/ambulatory care, home health agency, skilled nursing facility, or hospital medical-surgical setting within the past five (5) years preferred.
• Experience working with patients who have co-occurring mental health, substance abuse, and physical health issues. Experience working with community agencies and health care providers.

KNOWLEDGE/SKILLS/ABILITIES:

• Basic knowledge of psychopharmacology for common mental health disorders.
• Commitment to ethical practice of social work principles (patient self-determination, privacy, dignity, cultural sensitivity).
• Knowledge of behavioral health conditions, evidence-based guidelines, mental health risk assessment, and patient education preferred.
• Ability to manage complex mental health issues utilizing assessment skills and protocols.
• Excellent assessment, triage and critical thinking skills.
• Ability to implement evidence base interventions and protocols for mental health conditions.
• Ability to travel to work in the physician offices, attend meetings and conferences as needed.
• Demonstrates customer focused interpersonal skills, and the ability with the understanding of cultural diversity to interact in an effective manner with practitioners, patients, and families.
• Demonstrates ability to work autonomously and be directly accountable for practice.
• Excellent computer knowledge and capability to use computer; i.e. Microsoft Word, Excel. Epic experience preferred.
• Demonstrates ability to develop positive, longitudinal relationships and set appropriate boundaries with patients/families.

WORKING CONDITIONS/ PHYSICAL DEMANDS:

• Ability to maintain regular, punctual attendance consistent with the ADA, FMLA and other federal, state and local standards.
• Constant Sitting, near vison, finger dexterity, talking, hearing, tasting/smelling.
• Frequent Depth perception.
• Frequent lifting up to 10 lbs.
• Occasional Standing, walking, lifting/carrying, pushing/pulling, stooping, kneeling, crouching, squatting, crawling, far vision.
• Occasional lifting up to 50 lbs.