Registered Nurse Care Manager

This 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. 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 leadership to continuously evaluate processes, identify problems, and propose/develop process improvement strategies to enhance care management and Patient‑Centred Medical Home delivery of care models. Understand and adhere to compliance standards as outlined in the organization’s Corporate Compliance Policy, Code of Conduct, and Conflict of Interest Policy. Keep abreast of all pertinent federal, state, and organizational 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 Service Collaboration Integrity Respect Professionalism Learning Education / Licenses / Certificates Degree as RN (Associate’s, Bachelor’s, or Master’s). 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. Benefits Loan repayment through the NHSC and Michigan State Loan Repayment Program for select roles Medical, Dental and Vision Insurance for you and your family Generous Paid Time Off benefit – 4 weeks per year for full time Paid 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 Plans Pet Insurance Employee Assistance Program Our 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. #J-18808-Ljbffr