Summary:
RN Care Managers provide care management and care coordination for high risk patients in the primary care setting. Integrates evidence-based clinical guidelines, preventive guidelines, and protocols, in the development of individualized care plans that are patient-centric, promoting quality and efficiency in the delivery of health care. Provides targeted interventions to avoid hospitalization and emergency room visits and promote the self-management of chronic disease. Coordinates care across settings and helps patients/families understand health care options.
Posted Date:
3/9/2021
Job Location:
St Clair Shores, MI
Position Type:
Full-time

Department Description:

Pointe Family Physicians is located on 9 Mile Rd, east of I-94 in St. Clair Shores.

This position will work on site at Cornerstone-Pointe Family Physicians but candidate will be employed through Ascension.

To apply for this position, click on this LINK to be redirected to the Ascension Careers site.

In partnership with the primary care practice leadership team, the Care Manager leads care management activities within the practice through process improvement, workflow redesign,  and provision of assistance and training to other members of the care team. Serves in an expanded health care role to collaborate with specialists, members of the health care team, and patients/families to ensure the  delivery of quality, efficient, and cost-effective health care services.

  1. Identifies the targeted high risk population within practice site(s)
  2. Collaborates with PCP, patients, and members of the health care team,to develop and monitor a comprehensive individualized plan of care and targeted interventions.
  3. Provides patient self-management support with a focus on empowering the patient/family to build capacity  for self- care. 
  4. Coordinates patient care through ongoing collaboration with PCP,  community, and other members of the healthcare system that includes patient/family as active members  of the team.  
  5. Provides follow-up with patient/family when patient transitions from one setting to another with a goal toward reducing hospital readmissions.
  6. Maintains required documentation for all care management activities. 


Qualifications:

Licensure / Certification / Registration:

  • Registered Nurse credentialed from the Michigan Board of Nursing obtained prior to hire date or job transfer date required.
  • BLS Provider credentialed from the American Heart Association (AHA) preferred.

Education:

  • Diploma from an accredited school/college of nursing required.

Work Experience:

  • Previous care and/or case management experience preferred