Registered NURSE; Primary Care - RN Complex Care Navigator

Michigan Medicine improves the health of patients, populations and communities through excellence in education, patient care, community service, research and technology development, and through leadership activities in Michigan, nationally and internationally. Our mission is guided by our Strategic Principles and has three critical components; patient care, education and research that together enhance our contribution to society.

RN Complex Care Manager (Care Navigator):

• Identifies the targeted high- risk population within practice site(s), risk stratification, and patient lists.
• Assess over time the health care, educational, and psychosocial needs of the patient/family. Uses standardized assessment tools such as SDOH, pain scale, depression screening, functionality, and health risk assessment.
• Collaborates with Provider and Interdisciplinary team, including continuum of care settings and community. Responsible for developing a comprehensive individualized plan of care and targeted interventions. Continually monitors patient/family response to plan of care, and revises the care plan as indicated.
• Provides patient self-management support with a focus on empowering the patient/family to build capacity for self- care.
• Implements systems of care that facilitate close monitoring of high-risk patients to prevent and/or intervene early during acute exacerbations.
• Implements clinical interventions and protocols based on risk stratification and evidence-based clinical guidelines.
• Coordinates patient care through ongoing collaboration with providers, patient/family, community, and other members of the health care team. Fosters an interdisciplinary team approach and includes patient/family as active members of the team. Takes the lead in ensuring the continuity of care which extends beyond the practice boundaries. Serves as liaison to acute care hospitals, specialists, and post-acute care services.
• Provides follow-up with patient/family when patient transitions from one setting to another. Completes timely post-discharge calls:
  Medication reconciliation, PCP or specialist follow-up appointment, assess symptoms, assess psycho-social status, teach warning signs, review discharge instructions, coordination of care, review goals of care discussion and problem solve barriers.
• Provides telephone triage and advice, patient education, and direct patient care and hand-offs.
• Provides functional supervision of assistive personnel.
• Demonstrates excellent written, verbal, and listening communication skills, positive relationship building skills, and critical analysis skills.
• Maintains required documentation for all care activities.
• Works with practice and PO/PHO leadership to continuously evaluate process, identify problems, and propose/develop process improvement strategies to enhance care management and Patient Centered Medical Home delivery of care model.

SKILLS AND ABILITIES:

• 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, and 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.

Expectations of the position:

• Demonstrates excellent communication--both verbal and written
• Excellent interpersonal and facilitation skills
• Ability to affect change, work 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
• Demonstrated excellent attendance and punctuality

• Current Michigan license as a Registered Nurse
• Two years of experience working with complex adult and pediatric patients
• Two years of experience in case management, IP or ambulatory…