Registered Nurse Care Manager

RN Care ManagerThis is a full time, benefit eligible position typically working Monday - Friday 8am-5pm onsite at our Cherry Street Health Center. This role will travel to other Cherry Health medical sites around West Michigan.The RN Care Manager is responsible for conducting Medicare Annual Wellness Visits (AWV) across multiple Cherry Health medical sites. The Care Manager will work collaboratively with the primary care provider and the Medicare beneficiary to conduct a health risk assessment and preventative services plan to promote health and wellness for the year ahead. As part of an expanded healthcare role, the Care Manager collaborates with specialists, members of the healthcare team, and patients/families to ensure the delivery of quality, efficient, and cost-effective healthcare services. This position will assist providers in achieving desired patient outcomes by working collaboratively with providers, the multidisciplinary team, and the community medical neighborhood. The position requires adherence to organizational Policies, Procedures, Code of Ethics, and all licensing and accreditation standards. The RN must also represent the organization's mission in all actions and communications.Essential Duties and Responsibilities:Identify and outreach to patients due for Medicare AWVs utilizing targeted patient lists.Assess over time the healthcare, educational, and psychosocial needs of the patient/family using standardized assessment tools such as depression screening, functionality, and health risk assessments.Collaborate with primary care providers, patients, and members of the healthcare team, including continuum of care settings and the community, to develop a comprehensive individualized care plan and targeted interventions.Provide patient self-management support, focusing on empowering the patient/family to build capacity for self-care.Act as the lead in ensuring continuity of care that extends beyond the practice boundaries.Serve as a liaison to acute care hospitals, specialists, and post-acute care services.Provide follow-up and coordination with patients/families experiencing a discharge or transition from an inpatient acute care setting.Complete and maintain required documentation of timely post-hospital visit follow-up, medication reconciliation, primary care provider or specialist follow-up appointments, teaching warning signs, reviewing discharge instructions, coordinating care, and problem-solving barriers.Collaborate with Cherry Health's leadership to continuously evaluate processes, identify problems, and propose/develop process improvement strategies to enhance care management and Patient-Centered Medical Home delivery of care models.Understand and adhere to Cherry Health's compliance standards as they appear in Cherry Health's Corporate Compliance Policy, Code of Conduct, and Conflict of Interest Policy.Keep abreast of all pertinent federal, state, and Cherry Health regulations, laws, and policies as they currently exist and as they change or are modified.Other duties as assigned.Skills / Knowledge / Abilities:Basic Life Support/CPR certification according to requirements of license and/or certification.Demonstrate customer-focused interpersonal skills to interact effectively with practitioners, the interdisciplinary healthcare team, community agencies, patients, and families with diverse opinions, values, and cultural/religious ideals.Demonstrate excellent written, verbal, and listening communication skills, positive relationship-building skills, and critical analysis skills.Demonstrate the ability to work autonomously and be directly accountable for practice.Demonstrate the ability to influence and negotiate individual and group decision-making.Demonstrate leadership qualities, including time management, verbal and written communication skills, listening skills, problem-solving, critical thinking, analysis skills, decision-making, priority setting, work delegation, and work organization.Demonstrate the ability to develop positive, longitudinal relationships and set appropriate boundaries with patients/families.Knowledge of chronic conditions, evidence-based guidelines, prevention, wellness, health risk assessments, and patient education.Critical thinking skills and the ability to analyze complex data sets. Ability to manage complex clinical issues using assessment skills and protocols.Excellent assessment and triage skills. Ability to implement evidence-based interventions and protocols for chronic conditions.General computer knowledge and the ability to use a computer effectively.Competencies:Customer ServiceCollaborationIntegrityRespectProfessionalismLearningEducation / Licenses / Certificates:Degree as RN (Associates, Bachelors, or Masters).Licensure with the State of Michigan as a Registered Nurse required.Completion of self-management support training preferred.Experience:Three years of nursing experience with adult medicine patients in primary care/ambulatory care, home health agency, skilled nursing facility, or hospital medical-surgical settings within the past five years, or an equivalent combination of education and experience sufficient to successfully perform the essential duties of the job.Physical Requirements:Possible exposure to patients/clients with illnesses and/or infections.Frequent telephone and computer use, requiring manual dexterity for writing and computer use.Sitting, standing, or walking for extended periods.Specific vision abilities required by this job may include close vision, distance vision, and the ability to adjust focus.May require bending, squatting, or kneeling and lifting up to 50 pounds.Use of Personal Protective Equipment (PPE) as required.Client Population Served:May serve all patient populations.The essential functions of this position can be accomplished with or without accommodations. The above statements are intended to describe the general nature and level of work performed by individuals assigned to this classification. They are not intended to be construed as an exhaustive list of all responsibilities, duties, and skills required.Who we are:Cherry Health, Michigan's largest Federally Qualified Health Center (FQHC), operates in six counties across the state, is based in Grand Rapids. With a team of more than 800 health care professionals at 20 locations, Cherry Health focuses on removing barriers, expanding access, and delivering comprehensive quality health care services to underserved communities, regardless of an individual's insurance status or ability to pay. We provide primary care, dental, vision, behavioral health, pharmacy services, substance abuse services, residential re-entry services, school-based health centers and more.Our Mission:Cherry Health improves the health and wellness of individuals by providing comprehensive primary and behavioral health care while encouraging access by those who are underserved.Our Vision:Our community will be healthier because we will seek out and welcome those who need our services. All will be treated as family with integrated, coordinated care to improve health and personal well-being.Our Values:Collaboration – Support the Cherry Health mission by encouraging teamwork to accomplish organizational goals.Customer Service – Serve internal and external customers in a welcoming manner with compassionate care.Innovation – Embrace creativity to improve patient care and workplace efficiency while remaining curious and open to learning.Integrity – Uphold the highest ethical standards by being honest and trustworthy.Professionalism – Create a positive work environment where we care accountable for our decision, our action and the results.Benefits:Cherry Health has excellent benefit offerings dependent on employment status. Check out a sample of the benefits available to our team members below!Loan repayment through the NHSC and Michigan State Loan Repayment Program for select rolesMedical, Dental and Vision Insurance for you and your familyGenerous Paid Time Off benefit – 4 weeks per year for full timePaid holidays - 8 full day paid holidays (Including Black Friday!) and 2 half day paid holidays!403(b) Retirement Savings Plan with generous employer match - $ for $ match up to 5%MET and MESP 529 Savings PlansPet Insurance!Employee Assistance ProgramOur policy is to offer all employees and applicants for employment equal opportunity without regard to race, color, religion, gender, national origin, age, disability, genetic information, marital status, height, weight, sexual orientation, gender identity, or status as a covered veteran in accordance with applicable federal, state and local laws, or any other protected category.