Registered Nurse - EverCare Program

Join Hospice of Michigan – EverCare Program. We're seeking a compassionate Registered Nurse who is passionate about providing exceptional, patient-centered care. If you have experience in primary care, home care, geriatrics, care management, or assisted living, we'd love to hear from you.

All full-time and eligible part-time employees would have the following benefits:

• Health, Dental, and Vision insurance
• Paid parental leave
• Flexible spending account
• Health savings account
• Life insurance Tuition reimbursement
• Pet insurance
• Generous paid time off
• 403(b) retirement savings with company match

What You'll Do

• Serve as the primary RN care manager for a panel of medically complex older adults.
• Coordinate chronic disease management and care transitions to improve patient outcomes.
• Partner closely with Nurse Practitioners, physicians, and the interdisciplinary team to deliver proactive, value-based care.
• Delivers Chronic Care Management (CCM), Complex Chronic Care Management, and Principal Care Management (PCM) services in accordance with Medicare requirements, including obtaining and documenting patient consent, developing and maintaining comprehensive electronic care plans, and accurately tracking and documenting time to support billing of CCM/PCM codes.
• Develops, implements, and continuously updates a comprehensive, patient-centered care plan for each enrolled patient that addresses all chronic conditions, functional status, cognitive status, psychosocial needs, medications, preventive services, and patient/caregiver goals of care.
• Conducts scheduled telephonic and telehealth outreach to enrolled patients between provider encounters to assess symptoms, monitor disease control, reinforce the treatment plan, and identify early signs of clinical deterioration.
• Performs medication reconciliation and adherence assessments at every care management contact and following all transitions of care; identifies polypharmacy risks and potentially inappropriate medications in older adults and escalates findings to the Nurse Practitioner or collaborating physician.
• Supports Transitional Care Management (TCM) by tracking hospital admissions, emergency department visits, and skilled nursing facility stays for the panel; completes interactive contact within two business days of discharge; reconciles discharge medications and ensures timely post-discharge follow-up visits are scheduled to reduce avoidable readmissions.
• Prepares for and supports Annual Wellness Visits (AWVs), including completion of health risk assessments, screenings (cognitive, fall risk, depression, functional status), and preventive care planning in collaboration with the Nurse Practitioner.

Qualifications

• Current Michigan Registered Nurse (RN) license.
• Minimum of 3 years of clinical nursing experience.
• Experience in primary care, home care, geriatric care, care management, chronic disease management, or assisted living is strongly preferred.

Work Location: In person

Benefits:

Salary : $72,689 - $91,270