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Hours per Pay: 80
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Job Details:
  • Associate's Degree
  • Registered Nurse (RN)
  • 3 - 5 years of experience required
  • SUMMARY

    In conjuction with the Michigan Primary Care Transformation Project (MiPCT), the Advantage Health/Saint Mary's Medical Group is looking to fill a full-time Moderate Care Manager role.  Utilizes the chronic care model to provide care management and care coordination for adult and pediatric patients with mild to moderate illness in a primary care office setting.  Counsels patients to take an active role in both chronic disease and health prevention utilizing self-management support and patient education.  Actively manages 90 moderate risk patients at a time.   As a key member of the office team, works closely with Primary Care Physicians (PCP) and members of the health care team to coordinate care and empower patients to manage their chronic conditions and ensure the delivery of quality, efficient, patient centered, and cost-effective healthcare services.  Provides leadership to office on quality metrics to supports optimal quality performance in the ambulatory physician’s practice setting through a population management approach.

    QUALIFICATIONS

    Education

    Minimum – Bachelors of Science in Nursing (BSN) or equivalent experience.

     Preferred -  BSN

    Credentials/Licensure

                   Minimum – Current RN licensure in the State of Michigan.

    Experience

    Minimum - 3 years Medical Surgery or Chronic Disease Management experience.  Must be able to demonstrate    current clinical competence within the RN scope of nursing practice as identified within the ANA Scope of Practice and the state of Michigan. 

                  Preferred – Previous case management experience.

    Other Knowledge, Skills and Abilities

    Minimum: 

    §        Bi-lingual (Spanish/English) required at Clinica Santa Maria and Sparta Family Health Center.

    §        Knowledge of chronic disease and preventive health standards applicable to a population management approach.

    §        Excellent customer service skills and ability to communicate effectively with a variety of audiences.

    §        Ability to work collaboratively in a team-oriented environment.

    §        Ability to interpret laboratory and radiology test results.

    §        General knowledge of pharmaceutical formularies.

    §        Ability to demonstrate assessment skills, independent thinking and decision-making.

    §        General understanding of patient insurance benefit plan designs and coverage levels

    §        Knowledge of and ability to coordinate community resources applicable to office practice.

    §        Effective verbal, written, and interpersonal communication skills with the ability to comfortably interact with diverse populations.

    §        Strong organizational skills in order to work under time constraints and be able to adapt to medical situations.

    §        Ability to handle patient and organizational information in a confidential manner.

    §        Ability to demonstrate competency with a standard desktop and Windows-based computer system including but not limited to email, e-learning, intranet and computer navigation. Ability to use other software as required while performing the essential functions of the job.

    §        Proficient/knowledgeable in medical terminology.

    §        Must be able to type at least 30 adjusted words per minute.

    Physical

                   Minimum

    §        Constant reaching, standing, walking, lifting and bending at waist. 

    §        Frequent computer work.

    §        Ability to function in our working conditions.

     

    WORKING CONDITIONS

    Fast paced environment, managing multiple tasks and patients at the same time while showing respect and courtesy to each individual. Possible exposure to infectious disease, hazardous chemicals and frequent blood and body fluid. Ability to work flexible schedules.

    AGES OF PATIENTS SERVED

    aNewborns               aPediatrics               aAdolescents               aAdults               aGeriatrics             ? NA

    ORGANIZATIONAL EXPECTATIONS

    §        Flexibility – Demonstrates exceptional ability and willingness to take on new and additional responsibilities.  Embraces new ideas and cultural differences while managing competing priorities.

    §        Accountability – Willingly accepts personal responsibility for decisions, actions, attitudes and behaviors, which contribute to the overall effectiveness of the organization.  Accepts responsibility for personal attendance expectation.  Communicates effectively, follows through on assignments, uses resources efficiently, participates in learning opportunities and treats others with respect and dignity.

    §        Excellence – Serves as a role model and performs job responsibilities to the highest standards in every situation.  Delivers “Something More” that ensures a more complete and personally satisfying experience for every customer.

    §        Focus – Understands and demonstrates behaviors consistent with the mission and values of the organization while contributing to the overall success of the strategic plan.  All actions are rooted in providing excellent customer service.

    ESSENTIAL FUNCTIONS

    §        Utilizes the Nursing Process to perform the following functions:

    1)     Assessment – Completes and documents holistic assessment. Formulates nursing problems and diagnoses. 

    2)     Planning – Initiates an individualized plan of care based on actual and/or potential medical problems.

    3)     Implementation – Prioritizes nursing interventions.  Demonstrates knowledge of standards of care and practice.

    4)     Evaluation – Reviews and revises the plan of care based on individual patient response.

    §        Utilizes PCP referral and registry reports to identify patients with chronic conditions and gaps in clinical care.

    §        Utilizes patient list to ensure overdue tests/labs are completed, monitors individual patient progress and population management. 

    §        Consults with physicians, providers, and other team members as appropriate to document complete and accurate patient records related to calls received, services rendered, follow-up provided, and/or outcomes.

    §        Implements evidence-based care, chronic disease protocols and guidelines. 

    §        Provides follow up with patient/family when patient transitions from one setting to another. 

    §        Completes post hospital discharge calls:   Medication reconciliation, PCP or specialist follow up appointment, assesses symptoms, teaches warning signs, coordinates care, reviews discharge instructions, and problem-solves barriers.  

    §        Works closely with the PHO Medical Management Department to monitor office performance and identify quality/utilization opportunities to ensure optimal quality performance of the primary care office.

    §        Works collaboratively with physicians, care teams, and practice leader to ensure outreach is completed to patients who do not regularly visit the practice.

    §        Educates office team and monitors office quality performance.

    §        Maintains required documentation for all care management activities.

    §        Works with practice and PHO Medical Management Department to continuously evaluate processes, identify problems, and propose/develop process improvement strategies to enhance the Patient Centered Medical Home.

    §        Utilizes the chronic care model and motivational interviewing techniques to perform comprehensive assessments which includes assessing patient confidence levels for change. 

    §        Coordinates applicable community services and resources. 

    §        Performs other duties as assigned.

     

     

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