RN Care Manager; ACO

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, improved 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 via the ACO.
    
    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 medical home network 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 8 main accountabilities.
• Identifying Population of Focus through risk stratification. 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.
• Provide Transition of Care Services following inpatient discharges.
• 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.
• MARGINAL JOB DUTIES
  • Participates in Patient Centered Medical Home recognition activities.
  • Other duties as assigned.
• JOB SPECIFICATIONS
  • Education:
    • Graduate from 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…