The RN Care Manager supports the primary care physician network by providing service to patients with chronic conditions who are at risk for disease progression, complications, cognitive and functional decline. In collaboration with the physician and interdisciplinary team, the RN Care Manager develops and implements an individualized care plan designed to promote the patient’s understanding and management of their condition, optimize quality of life, and improve clinical outcomes. This position provides service in the primary care practices and individual patient homes.
- Actively seeks to engage moderate and high risk patients in the care management program through proactive telephonic outreach, practice and home based encounters.
- Conduct comprehensive assessments (in-home, in primary care practice or telephonically) to identify the patient’s needs and goals, health behaviors, functional and/or cognitive impairment, psychosocial issues, environment, and areas of risk that may impact the patient’s adherence to the treatment plan.
- In collaboration with the multi-disciplinary care team, develops an individualized care plan and intervention strategies to meet the patients needs and focused on improved clinical outcomes and patient satisfaction. The RN Care Manager will monitor the care plan for effectiveness, review with the primary care physician, and modify as needed to optimize the patient’s progress and well-being.
- Establish and support the patient’s self- management goals
- Provide education on management of chronic conditions and enhances the patient’s self-efficacy to prevent progression or exacerbation of chronic illness and promote healthy behavior change.
- Coordinate care transitions and monitoring of high risk patients following hospital and sub-acute discharges to ensure timely follow-up with primary care and prevent readmissions.
- Facilitate discussions with the patient and caregiver regarding advanced directives and palliative care.
- Align resources with the patient including referrals to other disciplines of the care management team, home care, community resources, and other healthcare providers.
- Actively participate in multi-disciplinary team conferences.
- Maintain timely and complete medical record documentation and billing of all care management encounters.
- Work with the practice and physician organization to continuously evaluate processes and develop improvements to advance the care management program'
'Benefits: * Health insurance
- Dental insurance
- Vision insurance
- Retirement plan
- Paid time off
- Flexible scheduleThis Company Describes Its Culture as:
- Stable -- traditional, stable, strong processes
- People-oriented -- supportive and fairness-focused
- Team-oriented -- cooperative and collaborative
Work Location:
- 30600 Telegraph Rd., Ste 4000 Bingham Farms, MI 48025
Relocation Assistance Provided:
Schedule:
Job Type: Full-time
Schedule:
Education:
Experience:
- Nursing: 1 year (Preferred)
- Case management: 1 year (Preferred)
License/Certification:
Willingness to travel:
Work Location: In person