Position Summary:

The Care Management RN performs care management for chronically ill patients. Working in collaboration and continuous partnership with the chronically ill patients and their family/caregiver(s), clinic providers and community resources in a team approach to increase patients’ ability for self-management and shared decision-making.

Position Responsibilities:

· Can fulfill the organizations mission to provide accessible, high quality health care services.

· Build strong relationships with community agencies and build a resource library that supports social determinants of health for the practices patients.

· Assess clients’ needs for services and cooperatively develop an integrated patient centered care plan and goals with the client/family and other providers as assigned by the supervisor.

· Complies with documentation requirements of the CM program by carrying out the care plan with the patient, family/caregiver(s) and providers and recording in the EHR.

· Monitors adherence to care plans, evaluations effectiveness, monitors patient progress in a timely manner, and facilitates changes as needed.

· Adheres to HIPAA requirements and maintains confidentiality of all data, including patient/family, employee, and operations information.

· Creates an ongoing process for patient and family/caregiver(s) to determine and request the level of care coordination support they desire.

· Facilitates patient access to appropriate medical and specialty providers.

· Coordinates transition of inpatient to outpatient care to decrease readmission rates.

· Work closely with providers and staff to manage symptoms, medications, and patient/family education.

· Supports patient self-management of disease and behavior modification interventions.

· Provide guidance to Chronic Care Coordinators as needed.

· Attend and participate in staff meetings.

· May be asked to perform other duties that align with Michigan Primary Care Partners mission.

Position Requirements:

· Supports the Mission, Value and Vision of Michigan Primary Care Partners (MPCP)

· Knowledge of community resources.

· Skill in providing excellent customer service and support; organizing and prioritizing workload and meeting deadlines; and excellent written and verbal communication.

· Ability to interact effectively and professionally with persons from diverse cultural, socioeconomic, education, racial, ethnic, and professional backgrounds.

· Ability to work effectively with managers, co-workers, members of the public and professional groups.

· Ability to work as an effective team member; function independently, exercise sound judgment and initiative; be flexible to shift priorities; maintain confidentiality; establish and maintain effective interpersonal work relationships, effectively assist providers; work toward goals and objectives of priorities.

· Ability to follow MPCP Clinic practice guidelines.

· Ability to receive constructive feedback including evaluation of positions productivity and practice attributes.

Minimum Requirements:

Ability to perform each position responsibility satisfactorily with or without reasonable accommodation. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential duties of the position.

· Ability to understand that safety is a condition of employment. Unsafe acts or conditions will be reported to the supervisor or Site Supervisor.

· Must be computer literate with ability to enter information in the EHR system and compile reports or data as requested.

· Must be able to read, write and speak English.

Education and/or Experience:

· Required RN degree from an accredited agency.

· 1 year of relevant experience clinical nursing and/or case management/managed care or related field required.

· Preferred Experience working in a physician's office/ clinic setting.

Special Requirements:

Must be willing to travel between MPCP clinics as needed (Reed City, Stanwood, Big Rapids).

Appearance Standards:

This position shall follow the appearance standards as outlined in the MPCP Personnel Appearance Policy.

The specific statements shown in each section of this Job Description are not intended to be all-inclusive. They represent typical elements and criteria considered necessary to perform the job successfully. The job’s responsibilities/tasks may be modified and/or expanded over time. MPCP will inform the employee when changes in the respective job description are made.

Job Type: Full-time

Benefits:

• 401(k)
• Health insurance
• Paid time off

Schedule:

• 8 hour shift
• Monday to Friday

Work setting:

• Clinic

Work Location: In person