Job Number: HAFP-CARE MGMT-135-01
Number of Hours: Full-time (Leased Portage)
Location: Hancock, MI
Provides care management for adult and pediatric patients with moderate or complex illness in the primary care setting under minimal supervision. Serves in an expanded health care role to collaborate with specialist, members of the health care team, and patients/families to ensure the delivery of quality, efficient, and cost effective health care services. Assesses plans, implements, coordinates, monitors, and evaluates all options and services with the goal of optimizing the patients’ health status. 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.
Manages a caseload of approximately 250 patients and provides targeted interventions to avoid hospitalization and emergency room visits. Coordinates care across settings and helps patient/families understand health care options.
Education, Training, Licensing and Credentialing
- Current Michigan Registered Nurse
- 3 years of experience with adult medicine and pediatric patients in primary care/ambulatory care, home health agency, skilled nursing facility, or hospital medical-surgical setting, within the past 5 years.
- Knowledge of chronic conditions, evidence based guidelines, prevention, wellness, health risk assessment, and patient education.
- Critical thinking skills and ability to analyze complex data sets. Ability to manage complex clinical issues utilizing assessment skills and protocols.
- Excellent assessment and triage skills. Ability to implement evidence based interventions and protocols for chronic conditions.
- Demonstrates excellent verbal and written communication skills.
- Excellent interpersonal and facilitation skills.
- Ability to affect change, works as a productive and effective team member, and adapt to changing needs/priorities.
- Time management, priority setting, work delegation, and work organization.
- General computer knowledge and capability to use computer and electronic health record.
- Completion of self-management support training
- Care Management experience
- Experience as participant in continues quality improvement
Experience and Skills
- Demonstrates customer focused interpersonal skills to interact in an effective manner with practitioners, the interdisciplinary health care team, community agencies, patients, and families with diverse opinions, values, religious, and cultural ideals.
- Demonstrates ability to work autonomously and be directly accountable for practice.
- Demonstrates ability to influence and negotiate individual and group decision-making.
- Demonstrates ability to function effectively in a fluid, dynamic, and rapidly changing environment.
- Demonstrates leadership qualities including time management, verbal and written communication skills, listening skills, problem solving, critical thinking, analysis skills and decision-making, priority setting, work delegation, and work organization.
- Demonstrates ability to develop positive, longitudinal relationships, and set appropriate boundaries with patients/families.
Physical Demands, Working Conditions and Travel Requirements
- Prolonged, extensive, or considerable standing/walking/sitting
- Ability to communicate and respond effectively
- Assists with lifting and moving patients
- Lifts supplies/equipment
- Considerable reaching, stooping, bending, kneeling and crouching
- Requires visual acuity to perform required tasks
- Requires the ability to work without direct supervision
- Required to communicate with physicians, patients, families, caregivers and the healthcare team
- Regularly exposed to the risk of blood borne diseases
- May be exposed to infections and contagious diseases
- Exposed to housekeeping/cleaning agents/chemicals
- Contact with patients under wide variety of circumstances
- Subject to varying and unpredictable situations
- Subject to many interruptions
- Occasional pressure due to multiple calls and inquiries
- Occasional travel required; local, region