Provides care management and care coordination for adult and pediatric patients with complex illness, in the primary care setting, under minimal supervision.
In partnership with the primary care practice leadership team, the Complex Care Manager leads care management within the team through process improvement, workflow redesign, providing assistance with training, and delegating to other members of the team.
Serves in an expanded health care role to collaborate with specialists, members of the health care team, and patients/families to ensure the delivery of quality, efficient, and cost-effective health care services.
Assesses plans, implements, coordinates, monitors and evaluates all options and services with the goal of optimizing the patient’s health status.
Integrates evidence-based clinical guidelines, preventive guidelines, and protocols, in the development of individualized care plans that are patient-centric, promoting quality and efficiency in the delivery of health care.
Manages a caseload of patients.
Provides targeted interventions to avoid hospitalization and emergency room visits. Coordinates care across settings and helps patient/families understand health care options.
RN Complex Care Manager (Care Navigator):
Identifies the targeted high risk population within practice site(s) per PCP/Palliative Care Provider referral, risk stratification, and patient lists.
Assesses 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 PCP and/or Palliative Care 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.
Im plements 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 PCP/Palliative Care Provider, 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-hospital follow-up: 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.
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.
Reviews the current literature regarding effective engagement and communication strategies, care management strategies, and behavior change strategies and incorporates into clinical practice.
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
Will provide CN support to the Briarwood Family Medicine Clinic
Will provide CN support to Palliative Care for EAA, Cancer Center and Briarwood
Current Michigan license as a Registered Nurse
Two years of experience with adult primary care patients within the past five (5) years
Two years of experience in case management, IP or ambulatory care.
Knowledge and experience with management of chronic conditions, evidence based guidelines, prevention, wellness, health risk assessment, and patient education
Critical thinking skills and ability to analyze complex data sets.
Ability to manage complex clinical issues utilizing assessment skills and protocols
Excellent assessment and triage skills.
Ability to implement evidence base interventions and protocols for chronic conditions
NOTE: Required qualifications must be met by the candidate in order to be interviewed and considered for the position.
RESUME REQUIRED (for both internal & external applicants): You must attach a complete and accurate resume to be fully considered for this position.
Preferred previous experience within the last 5 years in Hospice/Palliative Care
Demonstrated partnership and leadership with members of the health care team in current chronic care initiatives as validated by performance evaluations and references.
Completion of self-management support training.
Certification as a Case Manager by the Case Management Society of America/AAACN and/or CHPN (Hospice/Palliative Care Nursing Certification within 3 years of hire
Ambulatory Care Experience
Michigan Medicine is one of the largest health care complexes in the world and has been the site of many groundbreaking medical and technological advancements since the opening of the U-M Medical School in 1850. Michigan medicine is comprised of over 26,000 employees and our vision is to attract, inspire, and develop outstanding people in medicine, sciences, and healthcare to become one of the world's most distinguished academic health systems. In some way, great or small, every person here helps to advance this world-class institution. Work at Michigan Medicine and become a victor for the greater good.
What Benefits can you Look Forward to?
Nursing at Michigan offers a competitive salary with excellent benefits!
Salary range for Registered Nurses- $67,815.44 - $107,275.37
Evening Shift Differential- $2.55 per hour
Night Shift Differential- $3.40 per hour
Weekend Differential- $1.75 per hour
Hours/Week: 40 hours per week
Shift/Hours/Days: Day/Evening shift.
***NOTE: This is a multi-unit position. The schedule is primarily Monday through Friday, days with some early evening hours and may include some non-traditional hours with growth of the services. The RN needs to be available for in-person on-site visits when appropriate. This position may be allow for remote work.
Location: Briarwood Family Medicine.
Note: All new employees will be expected to float to a designated unit(s) in times of low census.
This position is covered under the collective bargaining agreement between the U-M and the Michigan Nurses Association and the U-M Professional Nurse Council union, which contains and settles all matters with respect to wages, benefits, hours and other terms and conditions of employment.
Michigan Medicine conducts background screening and pre-employment drug testing on job candidates upon acceptance of a contingent job offer and may use a third party administrator to conduct background screenings. Background screenings are performed in compliance with the Fair Credit Report Act. Pre-employment drug testing applies to all selected candidates, including new or additional faculty and staff appointments, as well as transfers from other U-M campuses.
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.
The University of Michigan is an equal opportunity/affirmative action employer.
Internal Number: 195430
About University of Michigan - Ann Arbor
A great university is made so by its faculty and staff, and Michigan is recognized as one of the best universities to work for in the country. The Michigan culture is known for engaging faculty and staff in all facets of the university to create a workplace that is vibrant and stimulating.For two consecutive years, the Chronicle of Higher Education has placed U-M in its "Great Colleges to Work For" survey. In particular, the university earns high marks for strong relations between faculty and administrators, a collaborative system of governance, strong pay and benefits, and a healthy work/life balance.