Allegan General Hospital seeks an RN Care Management Coordinator to work in our Continuing Care department.
JOB DUTIES INCLUDE, but may not be limited to:
- Assists provider referred or self-referred patients through the healthcare system by acting as a patient advocate and navigator.
- Communicates with providers and clinical staff to learn of high risk/high need patients who may benefit from enhanced health related communication, education, or other interventions.
- Provides patient education and health coaching to primary care patients; especially those with chronic care needs (e.g. congestive heart failure, chronic obstructive pulmonary disease, asthma, diabetes, etc.).
- Facilitates health and disease patient education via phone or in a face-to-face individual or group setting.
- Supports patient self-management of disease and behavior modification interventions.
- Assists patients with personalized goal setting and care plan development at their own readiness and education level.
- Coordinates continuity of patient care with external healthcare organizations and facilities; including the hospital admission, discharge, and follow-up appointment process. May assist Referral Coordinator and/or Quality Coordinator with continuity of patient care to include facilitating referrals to specialty providers and arranging follow-up care after an emergency department (ED) visit; keeping in mind the goal of reducing hospital readmissions and preventing unnecessary/inappropriate ED visits.
- Generates monthly gap analysis in conjunction with the Quality Coordinator to identify and communicate gaps in chronic care management of the professional practice's patients.
- Assists in the management of high-risk patient care, including management of patients with multiple co-morbidities and/or those at high-risk for readmission to a hospital setting. Updates the electronic medical record which may include enrolling patient(s) into appropriate protocols.
- Promotes clear communication within and among care team members; informing clinicians of patient new and updated care plans and protocols.
- Facilitates patient medication management/reconciliation within the appropriate scope of practice and based on provider orders and approved protocols.
- Participates in staff, clinical team, and clinic operations meetings as necessary and appropriate for data collection, health outcomes, reporting, clinical audits, and programmatic evaluation related to the Patient-Centered Medical Home, Medical Neighborhood, and quality improvement initiatives.
- Evaluates, in conjunction with the clinic leadership team and other quality team members, clinical care, utilization of resources, and the development of new clinical tools, forms and procedures.
- Assists in the development and maintenance of clinical practice policies and procedures.
- Participates in emergency preparedness activities and training; responds, as appropriate, to emerging issues such as rapid responses, code blue, and/or pandemic influenza.
- Supports the clinical team in required reporting concerns such as child and/or adult abuse, and reportable diseases, etc.
QUALIFICATIONS INCLUDE, but may not be limited to:
- Current, unencumbered license to practice registered nursing in the state of Michigan.
- Two (2) years clinical experience as a registered nurse (RN) in a physician office setting preferred.
- Current Basic Life Support Certification
- Ability to successfully handle stressful situations and meet deadlines.
- Thorough knowledge of standard practices, rules and regulations, as well as theory related to nursing
- Knowledge of aseptic technique, human anatomy and physiology.
- Ability to create and maintain accurate records, use an electronic medical record.
- Proficient in oral, written, and interpersonal communication skills with members of the healthcare team, patients, and community representatives.
- Ability to set priorities and anticipate primary care provider needs related to patient care management.
- Strong organizational skills and punctuality.
- Professionalism and friendly, outgoing, and engaging
Allegan General Hospital is an Equal Opportunity Employer.
