The RN Care Manager will work together with other members of the Care Team to provide high quality, well-coordinated, highly organized, patient-centered care to patients and their families/care givers/support systems. The CM primary focus will be the ongoing and/or intermittent management of patients identified as high risk via a comprehensive risk stratification process or otherwise identified by providers as needing care management. The CM acts in the capacity of a clinical support role to the Provider led Care Team and is an integrated, essential member of the care team for high risk patients. The RN Care Manager supports GLBHC sites in providing a team-based approach to care in the Patient Centered Medical Home (PCMH). Participates in activities related to Quality Improvement. The Desktop Management Nurse will monitor and manage provider desktops per the Desktop Management Protocol. The Nurse will provide professional telephone consultation and education, telephone triage and advice. The Desktop Management Nurse will assist in determining the urgency of care needed, referring to or scheduling appointments with providers.
ESSENTIAL JOB DUTIES FOR CARE MANAGEMENT NURSING
Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Primary Accountabilities
At Great Lakes Bay Health Centers the primary accountability of the Care Manager role will be to facilitate and guide patients through ongoing clinical and self-management support resulting in improved access, improves clinical outcomes or decreased cost of care as a key aspect of Patient Centered Care through outreach, enrollment, engagement, education, individualized care planning and self-management support strategies. The CM will focus on improving functional health status and decreasing disease burden while educating and empowering patients to actively participate in their care. The CM will identify patients with a high risk score as defined in the population health management system and engage patients in the CM program. As a driver of the Population Health strategy, the CM will gather data on the populations of focus, stratify relevant metrics/risk factors, and engage patients in comprehensive Care Management engaging other care teams such as Community Health Worker, Integrated Behavioral Health, and others as necessary. The CM will partner with and guide the care teams to ensure safe, timely, efficient and effective transitions of care for patients – both within and outside of the primary care practice. The role of the Clinical/Chronic Care Manager is focused around 7 main accountabilities.
- PhPIdentifying Population of Focus through risk stratification or provider referral. Risk scores include, at a minimum a collection of data on the following characteristics:
- Diseases diagnosis
- Social Determinants of Health
- ER and Hospital Admissions
- Behavioral Health conditions and indicators
- Understanding of contributing factors to risk score and developing a relevant and appropriate care plan.
- Patient Outreach & Enrollment in Care Management Program.
- Collaborate to Develop Individualized Care Plan.
- Review and Update Care Plan routinely.
- Provide Clinical support and Care Management, Education, Self-Management Support and ongoing communication with patients on a CM panel/registry.
- Integration and facilitation of relevant and comprehensive care team.
Operational Excellence
- Uses professional skills to the best of their ability
- Provides a positive patient-centered experience for every patient
- Considers safety of patients and works to help provide a safe environment
- Maintains a current up-to-date knowledge of new policies and procedures
- Follows and optimizes concepts of Patient Centered Care Delivery
- Follow the minimum set protocols for patient engagement, documentation and care management interventions
Relationship Management
- Works collaboratively with all staff, providers and leadership
- Engages others as part of a team-oriented philosophy
- The CM will work with practice leadership, providers, clinical staff and ancillary care teams, as well as with patients, families/caregivers, in order to achieve healthcare and lifestyle goals and maintain open lines of communication across the care team.
ESSENTIAL JOB DUTIES FOR DESKTOP MANAGEMENT NURSING
Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
- Monitors and managers provider desktops per desktop management protocol.
- Is responsible for documenting accurate and pertinent patient information in a timely manner. Documents all aspects of nursing care and patient education in EMR. Reviews flags/alerts, and provides follow-up as needed.
- Refers urgent calls or consults with appropriate provider and nursing staff based on patient’s home site.
- Provides patients with test results and follow up care of instructions.
- Provides patient education utilizing tools to identify and manage (within scope of practice) common development milestones (e.g. reproductive health, prenatal, childhood developmental stages), disease prevention (e.g. immunization, sex education including STI treatment and follow up), acute and chronic illness related to conditions (e.g. colds, arthritis, asthma, diabetes) affecting children and adults. Provides information on available community resources.
- Supports care management activities by participating in pre-planning of scheduled visits, tracking, hospital follow-up care, and outreach related to health maintenance and chronic disease care.
Note: This job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for the job. Duties, responsibilities and activities may change at any time with or without notice.
MARGINAL JOB DUTIES
- articipates in Patient Centered Medical Home recognition activities.
- Provides input to provider schedule changes.
- Other duties as assigned.
JOB SPECIFICATIONS
- Education:
- Graduate form an accredited professional nursing program; BSN strongly preferred.
- Trained and proficient in Motivational Interviewing skills within 60 days of employment and bi-annually at a minimum
- Licensure: Registered Nurse with current licensure to practice in the State of Michigan. Basic Life Support certification.
- Experience and Key Skills:
- Possess a professional, positive, team-oriented attitude
- Ability to communicate well with others through written and verbal interpersonal communication skills
- Ability to perform routine assignments independently
- Demonstrate strong assessment skills (professional, situational & clinical)
- Possess knowledge/expertise related to Chronic Care Management
- Ability to lead and engage in Motivational Interviewing techniques
- Possess basic computer skills and experience with Office product suite (Outlook, Word, Excel)
- Demonstrate knowledge and proficiency with EHR/Practice Management, and Population Health Management software systems
- Possess knowledge/expertise related to concepts of Population Health Management
- Proficiency in analyzing, stratifying and utilizing data to drive priorities
- Ability to multi-task and prioritize with minimal direction
- Demonstrate critical thinking skills and emotional intelligence in the workplace
- Demonstrate patient-centric model of care delivery and customer service
- Uphold the mission, values and principles of the organization
- Create and maintain a positive, team-based culture
- Physical Effort: Medium- Low
- Hours of Work: Full-time, flexible and varied. Some evening or weekend hours may be required.
- Travel: Travel between sites. Travel for meetings and or conferences if scheduled. Reimbursement as outlined under GLBHC’s policy or usage of an GLBHC vehicle as appropriate.
