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University of Michigan Health-West (Formally Metro Health) is looking for Case Manager (RN) - Clinically Integrated Network .

Under the direction of the Director, the Care Manager - RN provides care management services to adult and pediatric patients in an ambulatory setting. The Care Manager - RN performs clinical assessments and therapeutic interventions for complex patients with multiple chronic conditions and comorbidities. In addition, this position serves as community resource expert and care coordinator across the continuum of care. Furthermore, the Care Manager - RN optimizes care by engaging patients in the principles of self-management, goal setting and continuous improvement. This integral role expands primary care's scope of practice by focusing on patient's biopsychosocial needs to ensure the delivery of comprehensive, efficient and quality care.

Requirements:

• Possesses excellent time management, work delegation and organization skills.
• Exhibits creative problem solving and critical thinking skills
• Excellent written and verbal communication skills.
• Comprehensive knowledge of community resources.
• Knowledge of chronic medical and mental health conditions.
• Ability to triage and manage complex clinical issues utilizing assessment skills and protocols.
• Ability to work independently as well as in a team environment.
• Ability to adapt to changes in health care with the goal of improving quality, efficiency and cost effectiveness of care.
• Knowledge of electronic medical record documentation.

Qualifications:

• Current State of Michigan License (unrestricted) as a Registered Nurse (RN)
• Bachelor's in Nursing preferred
• Case Management Certified preferred
• Two (2) years of clinical nursing or RN experience required with three (3+) or more years of experience preferred.

Essential Functions and Responsibilities:

1. Receives and acts on referrals for moderate and complex patients through risk stratification, registries and provider referrals
2. Assesses patients' mental health and biopsychosocial needs through standardized assessments
3. Recommends treatment plans based on evidence based guidelines
4. Educates patients on preventive health, chronic illness and recommended treatments
5. Provides care coordination and follow-up for chronic medical conditions across the continuum of care
6. Follows patients longitudinally to evaluate treatment goals
7. Advocates for patients and family while maintaining professional boundaries
8. Educates and supports patients in the use of self-management techniques and develops action plans to encourage self-care
9. Facilitates transitions of care for admitted and discharged patients from the hospital or emergency department to ensure continuity of care
10. Consults with members of the care team throughout the continuum on treatment plans and follow-up care
11. Participates in process improvement activities to enhance primary care services and workflow
12. Offers group education classes for patients with chronic conditions