Registered Nurse Care Manager - Clarkston Medical Group

The Provider-Delivered Care Management (PDCM) Registered Nurse partners with primary care providers, patients, caregivers, and members of the interdisciplinary healthcare team to provide comprehensive care management for patients with chronic, complex, and high-risk health conditions.

The PDCM RN works collaboratively with patients to identify barriers to care, establish individualized goals, improve understanding and management of chronic disease, close gaps in care, and promote adherence to the patient's plan of care. The role focuses on improving clinical outcomes, reducing avoidable emergency department utilization and hospitalizations, facilitating safe transitions of care, and supporting patients in successfully managing their health in the home setting.

The Care Manager serves as a key point of contact between the patient and primary care team and facilitates timely communication of changes in patient condition to the appropriate provider. Care management may be delivered telephonically, electronically, virtually, or in person based on patient need and program requirements.

Essential Duties and Responsibilities

        Identify, assess, enroll, and manage appropriate patients for PDCM, chronic care management, transitional care management, and other care-management services according to organizational requirements.

        Perform comprehensive nursing assessments to identify clinical needs, barriers to care, health literacy needs, psychosocial concerns, medication issues, healthcare utilization patterns, and opportunities for intervention.

        Collaborate with the patient, primary care provider, and interdisciplinary care team to develop, implement, monitor, and update an individualized patient-centered care plan.

        Establish meaningful and measurable goals with patients and caregivers and provide ongoing coaching and follow-up to promote progress toward those goals.

        Serve as a primary point of contact for patients participating in care management, helping facilitate timely communication between patients and their primary care providers when clinical changes or concerns arise.

        Recognize changes in patient condition, identify red-flag symptoms, and escalate concerns promptly to the appropriate provider or level of care in accordance with nursing scope of practice, clinical protocols, and organizational policy.

        Provide patient education regarding appropriate use of the healthcare system, including when symptoms may be managed through the primary care office and when evaluation by urgent care or an emergency department may be indicated.