RN Care Manager - Care Management at Home Program

Employment Type:

Full time

Shift: Day Shift

Location:

Grand Rapids, Michigan

The RN Care Manager is a professional nurse who collaborates with physicians, facilities, health care team members and patient/families to manage chronic conditions and complex illness. The manager coordinates care for specific patient populations across the continuum and between care settings as an important member of the Patient Centered Medical Home team. The RN Care Manager provides supplemental Care Management services to our highest risk patients both at home and telephonically, working closely with Trinity Health Medical Group and affiliate office care teams.

The role focuses on engaging patients in Care Management to promote successful self-management, improve safety and quality of life in the community, reduce inappropriate utilization of emergency department and hospital resources, and guide patients toward their healthcare goals.

• Participate and engage patients in the assessment, planning, monitoring, and evaluation of ongoing care for chronic condition or complex illness management.
• Establish plans of care that include patient education, self‑management, care coordination, and the coordination of resources for effective, efficient, and appropriate patient care.
• Provide ongoing monitoring and evaluation of patient outcomes.
• Perform population health management duties, including risk stratification to identify high and rising‑risk patients, care coordination, patient engagement, and addressing SIOH needs to improve outcomes, reduce cost, and promote health equity.
• Assist patients in optimizing their health status by providing interventions designed to avoid hospitalization and emergency room visits.
• Provide Transitional Care Management to CHF patients discharged from the inpatient setting and to frequent emergency room users.

• Graduate of an accredited school of nursing.
• Bachelor of Science degree in Nursing required.
• Master's Degree in Nursing (or actively pursuing) preferred.
• Current licensure to practice nursing in Michigan.
• One year of experience in Case Management preferred.
• Three years of clinical experience in nursing required.
• Recent case management experience preferred.

We are an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or any other status protected by federal, state, or local law.