Sterling Area Health Center

RN Care Manager / Team Lead

Qualifications: Requires a current Michigan Registered Nurse license. Three 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 years. Knowledge of chronic conditions, evidence-based guidelines, prevention, wellness, health risk assessment, and patient education. Preferred Qualifications: bachelor’s degree or higher in clinical field. Care management experience and training.

Supervision: Lead RN Care Manager

Essential Functions and Responsibilities: Manages a caseload of complex patients. Provides targeted interventions to avoid hospitalization and emergency room visits. Coordinates care across settings and helps patient/families understand health care options. Infrequent, but possibility of home visits. Provides care management and care coordination for adult and pediatric patients with complex illness, in the primary care setting, under minimal supervision. In partnership with the primary care practice leadership team, the Care Manager serves in an expanded health care role to collaborate with specialists, members of the health care team, and patients/families to ensure the delivery of quality, efficient, and cost-effective health care services. Assesses plans, implements, coordinates, monitors, and evaluates all options and services with the goal of optimizing the patient's health status. Integrates evidence-based clinical guidelines, preventative guidelines, and protocols, in the development of individualized care plans that are patient-centric, promoting quality and efficiency in the delivery of care.

Major Duties and Responsibilities:

1. Identifies the targeted high-risk population within practice site(s) per PCP referral, risk stratification, and patient lists. Includes patients with repeated social and/or health crises.

2. Assesses the health care, educational, and psychosocial needs of the patient/family. Standardizes assessment tools such as depression screening, functionality, and health risk assessment.

3. Collaborates with PCP, patient, and members of the health care team, including continuum of care settings and community. Responsible for developing a comprehensive individualized plan of care and targeted interventions. Continually monitors patient/family response to plan of care and revises the care plan as indicated.
4. Provides patient self-management support with a focus on empowering the patient/family to build capacity for self-care.

5. Implements systems of care that facilitate close monitoring of high-risk patients to prevent and/or intervene early during acute exacerbations.

6. Implements clinical interventions and protocols based on protocols for chronic conditions and evidence-based clinical guidelines.

7. Provides follow-up with patient/family when patient transitions from one setting to another. Completes timely post-hospital follow-up: Medication reconciliation, PCP, or specialist follow-up appointment, assess symptoms, teach warning signs, review discharge instructions, coordination of care, and problem solve barriers.

8. Maintains required documentation for all Care Management activities.

9. Works with practice leadership to continuously evaluate process, identify problems, and propose/develop process improvement strategies to enhance care management and Patient Centered Medical care.

10. Reviews the current literature regarding effective engagement and communication strategies, care management strategies, and behavior change strategies and incorporates into clinical practice.

Skills and Abilities:

1. Demonstrates customer focused interpersonal skills to interact in an effective manner with practitioners, the interdisciplinary health care team, community agencies, patients, and families with diverse options, values, and religious and cultural ideals.

2. Demonstrates leadership qualities including time management, verbal, and written communications skills, listening skills, problem solving, critical thinking, analysis skills and decision-making, priority setting, work delegation, and work organization.

3. Demonstrates ability to develop positive, longitudinal relationships and set appropriate boundaries with patients/families.
4. Demonstrates critical thinking and the ability to analyze complex data sets while managing clinical issues and utilizing assessment skills protocols. Excellent assessment and triage skills.

5. Demonstrates ability to work autonomously and be directly accountable for practice.

6. Demonstrates ability to influence and negotiate individual and group decision-making.

7. Demonstrates ability to function effectively in a fluid, dynamic, and rapidly changing environment.

8. Ability to affect change, work as a productive and effective team member, and adapt to changing needs/priorities.

9. General computer knowledge and capability to use a computer.

Job Type:

· Full-time

Benefits:

• Health Insurance
• Dental Insurance
• Vision Insurance
• Life Insurance
• 403b retirement match
• Paid time off

Salary:

· $64,646.40 / year

Schedule:

• Monday to Friday

Work Location:

· Sterling (Various)

Job Type: Full-time

Pay: From $64,646.00 per year

Benefits:

• 403(b)
• Dental insurance
• Health insurance
• Life insurance
• Paid time off
• Vision insurance

Schedule:

• Monday to Friday

Work setting:

• Clinic

Ability to Relocate:

• Sterling, MI 48659: Relocate before starting work (Required)

Work Location: In person