Care Manager RN - Community Clinic * Days - 20hrs/wk
- Possesses excellent time management, work delegation and organization skills.
- Exhibits creative problem solving and critical thinking skills
- Excellent written and verbal communication skills.
- Comprehensive knowledge of community resources.
- Knowledge of chronic medical and mental health conditions.
- Ability to triage and manage complex clinical issues utilizing assessment skills and protocols.
- Ability to work independently as well as in a team environment.
- Ability to adapt to changes in health care with the goal of improving quality, efficiency and cost effectiveness of care.
- Knowledge of electronic medical record documentation.
- Current State of Michigan License (unrestricted) as a Registered Nurse (RN)
- Bachelor's in Nursing preferred
- Case Management Certified preferred
- Two (2) years of clinical nursing or RN experience required with three (3+) or more years of experience preferred.
- 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 the use of self-management techniques and develops action plans to encourage self-care
- Facilitates transitions of care for admitted and discharged patients from the hospital or emergency department to ensure continuity of care
- Consults with members of the care team throughout the continuum on treatment plans and follow-up care
- Participates in process improvement activities to enhance primary care services and workflow
- Offers group education classes for patients with chronic conditions
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