RN Care Manager

## RN Care ManagerApply: Grand Rapids, MI: Full time: Posted Today: JR100744Welcome to Cherry Health - video about Cherry Health**Overview of Position:**The RN Care Manager is responsible for comprehensively developing, implementing, monitoring, and evaluating individualized patient care plans for a targeted patient population. 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. This is a full time, benefit eligible position located onsite at our Heart of the City clinic working in our Adult Medicine clinic. Typically working Monday - Friday 8a-5pm. **Essential Duties and Responsibilities:*** Identify targeted high-risk populations within practice sites per primary care provider referral, risk stratification, and patient lists. This includes patients with repeated social and/or health crises.* 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. Continually monitor patient/family response to the plan of care and revise the care plan as necessary.* Provide patient self-management support, focusing on empowering the patient/family to build capacity for self-care.* Implement systems of care that facilitate close monitoring of high-risk patients to prevent and/or intervene early during acute exacerbations.* Implement clinical interventions and protocols based on risk stratification and evidence-based clinical guidelines.* 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 with patients/families when patients transition from one setting to another.* 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 the ability to function effectively in a fluid, dynamic, and rapidly changing environment.* 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 Service* Collaboration* Integrity* Respect* Professionalism* Learning**Education / Licenses / Certificates:*** Degree as RN (Associates or Bachelors).* Licensure with the State of Michigan as a Registered Nurse required.* Completion of self-management support training preferred.**Experience:**Three years of experience with adult medicine and pediatric 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. #J-18808-Ljbffr