Chronic Care RN (Support Coordinator)

Who Are We and What We Do? The Detroit Area Agency on Aging (DAAA) Region 1-A is a private, non-profit organization responsible for planning, coordinating, developing, and funding services for older adults in the cities of Detroit, the five Grosse Pointes, Hamtramck, Harper Woods, and Highland Park. 

We invite you to apply and be part of a team that truly values your contribution. We offer competitive wages and are committed to fostering a workplace where growth, teamwork, and serving the aging population are at the forefront. 

The Benefits of Joining Our Team - We Offer:

• Comprehensive Health Coverage - including medical, dental and vision
• Generous Paid Time Off
• Pet insurance
• Prescription drug insurance
• 403(b)
• Flexible work week schedule
• Supportive Culture - A collaborative and inclusive environment where your ideas are valued
• Career Development and Opportunities for Advancement
• Employee Recognition
• Other attractive benefits

Core Competencies

This individual must be able to demonstrate strong analytical and problem-solving skills, exercise sound judgment, activities. Demonstrate business and financial acumen. The person should be forward-thinking and creative, with high ethical standards, and an appropriate professional image. Operate as a strategic visionary with effective communication, sound technical skills, analytical ability, good judgment and strong operational focus. Be a well-organized and self-directed individual who is "politically savvy" and a team player.

Servant leadership:

The individual will be demonstrating excellent interpersonal skills with experience motivating, coaching, and developing high-performing teams. Must be able to demonstrate strong analytical and problem-solving skills, exercise sound judgment and ability to read / analyze complex documents. The ideal candidate must be forward-thinking, with high ethical standards and an appropriate professional image. The successful candidate must have outstanding communication skills, commitment to excellence and innovation, a passion for DAAA’s mission & vision.

Essential Duties:

·        Establishes a chronic care management plan that is mutually agreed upon by the health care team and the patient/family. Plans contain specific mutual self-management goals, objectives, and interventions with the patients are action oriented.

·        Evaluates the effectiveness of the plan in meeting established care goals; revises the plan as needed to reflect changing needs, issues and goals.

·        Collaborate with the healthcare team when utilizing community resources to meet the needs of patients/families. changes occur. Monitors and evaluates the progress of the patient. Initiates care conferences to discuss multidisciplinary team responsibilities, patient progress, new problems, etc.

·        Identifies and effectively promotes patient self-management and empowers patients/families to achieve maximum levels of wellness and independence. 

·        Interact professionally with patient/family and involves patient/family in the formation of plan of care.

·        Maintains regular, ongoing contact with clients, caregivers, specialists and service providers through home visits and phone calls.

·        Manages care transitions, which may include home visits, including providing referrals and facilitating follow-ups for the patient upon discharge from medical facility.

·        Performs medication reconciliation for all care transitions. 

·        Provides coverage across HBPC as needed. This may include clinical tasks. 

·        Participate in community health activities.

·        Participate in regular team meetings, peer review activities, and quality and organizational committees.

·        Participates in the orientation of new personnel. Precepts and mentors peers.

·        Promotes collaborative teamwork.

·        Abides by the organization's compliance program and requirements.

·        Works collaboratively with leadership team to improve and enhance care delivery through the evaluation, development and enhancement of policy and procedures.