Coordinator Care - Registered Nurse

Position Summary:

As an advocate for the patient, the RN care manager will assess, plan, implement, coordinate, monitor, and evaluate the options and services required to meet an individual’s health needs, using clinical and community resources to promote quality, cost effective outcomes.  Integrates evidenced based clinical guidelines, preventive guidelines, and protocols, in the development of individualized care plans that are patient centric.  Provides targeted interventions to avoid hospitalization and emergency room visits.

Essential Functions and Responsibilities:

1.    Provides telephonic and face-to-face comprehensive assessment and care management services to patients as part of an interdisciplinary team.

2.    Uses multi-dimensional assessment skills, risk assessment and screening tools to target high risk and vulnerable populations.

3.    Assesses over time the health care, educational, and psychosocial needs of the patient/caregiver.  Uses standardized assessment tools such as depression screening, functionality, and health risk assessment.

4.    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.

5.    Uses clinical judgment to determine level of care and collaborates with the PCP, patient and interdisciplinary team, including continuum of care settings and community. 

6.    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.

7.    Provides patient self-management support with a focus on empowering the patient/caregiver to build capacity for self-care.

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

9.    Implements clinical interventions and protocols based on risk stratification and evidenced-based clinical guidelines.

10.  Coordinates patient care through ongoing collaboration with PCP, patient/caregiver, McLaren Health Care, community agencies, health plans, and other disciplinary team members. 

11.  Fosters a team approach and includes patient/caregiver as active members of the team. 

12.  Takes the lead in ensuring the continuity of care which extends beyond the practice boundaries. 

13.  Serves as liaison to acute care hospitals, specialists, post-acute care services and community services.

14.  Demonstrates excellent written, verbal and listening communication skills, positive relationship building skills, and critical analysis skills.

15.  Maintains required documentation of all care management activities.

16.  Works with MPP Medical leadership to continuously evaluate process, identify problems, and propose/develop process improvement strategies to enhance care management and Patient Centered Medical Home delivery of care model.

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

18.  Other duties as assigned or when necessary to maintain efficient operations of the department and the Company as a whole.