This list contains only the countries for which job offers have been published in the selected language (e.g., in the French version, only job offers written in French are displayed, and in the English version, only those in English).
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.
Job Responsibility:
Provides telephonic and face-to-face comprehensive assessment and care management services to patients as part of an interdisciplinary team
Uses multi-dimensional assessment skills, risk assessment and screening tools to target high risk and vulnerable populations
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
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
Uses clinical judgment to determine level of care and collaborates with the PCP, patient and interdisciplinary team, including continuum of care settings and community
Requirements:
RN with a valid unrestricted Michigan license
Three (3) years clinical nursing experience serving chronically ill patients and extensive knowledge of issues associated with chronic care and geriatrics
Nice to have:
RN, BSN
Three (3) years experience in a health plan or Physician Organization environment with care coordination, care management, and/or population health