RN Care Manager

Welcome to Cherry Health - video about Cherry Health

Overview of Position:

The RN Care Manager is responsible for conducting Medicare Annual Wellness Visits (AWV) across multiple Cherry Health medical sites. The Care Manager will work collaboratively with the primary care provider and the Medicare beneficiary to conduct a health risk assessment and preventative services plan to promote health and wellness for the year ahead. As part of an expanded healthcare role the Care Manager collaborates with specialists members of the healthcare team and patients/families to ensure the delivery of quality efficient and cost-effective healthcare services. This position will assist providers in achieving desired patient outcomes by working collaboratively with providers the multidisciplinary team and the community medical neighborhood. The position requires adherence to organizational Policies Procedures Code of Ethics and all licensing and accreditation standards. The RN must also represent the organizations mission in all actions and communications.

This is a full time benefit eligible position typically working Monday - Friday 8am-5pm onsite at our Westside Health Center.

Essential Duties and Responsibilities:

• Identify and outreach to patients due for Medicare AWVs utilizing targeted patient lists.
• Assess over time the healthcare educational and psychosocial needs of the patient/family using standardized assessment tools such as depression screening functionality and health risk assessments.
• Collaborate with primary care providers patients and members of the healthcare team including continuum of care settings and the community to develop a comprehensive individualized care plan and targeted interventions.
• Provide patient self-management support focusing on empowering the patient/family to build capacity for self-care.
• Act as the lead in ensuring continuity of care that extends beyond the practice boundaries.
• Serve as a liaison to acute care hospitals specialists and post-acute care services.
• Provide follow-up and coordination with patients/families experiencing a discharge or transition from an inpatient acute care setting.
• Complete and maintain required documentation of timely post-hospital visit follow-up medication reconciliation primary care provider or specialist follow-up appointments teaching warning signs reviewing discharge instructions coordinating care and problem-solving barriers.
• Collaborate with Cherry Healths leadership to continuously evaluate processes identify problems and propose/develop process improvement strategies to enhance care management and Patient-Centered Medical Home delivery of care models.
• Understand and adhere to Cherry Healths compliance standards as they appear in Cherry Healths Corporate Compliance Policy Code of Conduct and Conflict of Interest Policy.
• Keep abreast of all pertinent federal state and Cherry Health regulations laws and policies as they currently exist and as they change or are modified.
• Other duties as assigned.
  

Skills / Knowledge / Abilities:

• Basic Life Support/CPR certification according to requirements of license and/or certification.
• Demonstrate customer-focused interpersonal skills to interact effectively with practitioners the interdisciplinary healthcare team community agencies patients and families with diverse opinions values and cultural/religious ideals.
• Demonstrate excellent written verbal and listening communication skills positive relationship-building skills and critical analysis skills.
• Demonstrate the ability to work autonomously and be directly accountable for practice.
• Demonstrate the ability to influence and negotiate individual and group decision-making.
• Demonstrate leadership qualities including time management verbal and written communication skills listening skills problem-solving critical thinking analysis skills decision-making priority setting work delegation and work organization.
• Demonstrate the ability to develop positive longitudinal relationships and set appropriate boundaries with patients/families.
• Knowledge of chronic conditions evidence-based guidelines prevention wellness health risk assessments and patient education.
• Critical thinking skills and the ability to analyze complex data sets. Ability to manage complex clinical issues using assessment skills and protocols.
• Excellent assessment and triage skills. Ability to implement evidence-based interventions and protocols for chronic conditions.
• General computer knowledge and the ability to use a computer effectively.
  

Competencies:

• Customer Service
• Collaboration
• Integrity
• Respect
• Professionalism
• Learning
  

Education / Licenses / Certificates:

• Degree as RN (Associates Bachelors or Masters).
• Licensure with the State of Michigan as a Registered Nurse required.
• Completion of self-management support training preferred.

Experience:

Three years of nursing experience with adult medicine patients in primary care/ambulatory care home health agency skilled nursing facility or hospital medical-surgical settings within the past five years or an equivalent combination of education and experience sufficient to successfully perform the essential duties of the job.

Physical Requirements:

• Possible exposure to patients/clients with illnesses and/or infections.
• Frequent telephone and computer use requiring manual dexterity for writing and computer use.
• Sitting standing or walking for extended periods.
• Specific vision abilities required by this job may include close vision distance vision and the ability to adjust focus.
• May require bending squatting or kneeling and lifting up to 50 pounds.
• Use of Personal Protective Equipment (PPE) as required.
  

Client Population Served:

May serve all patient populations.

The essential functions of this position can be accomplished with or without accommodations. The above statements are intended to describe the general nature and level of work performed by individuals assigned to this classification. They are not intended to be construed as an exhaustive list of all responsibilities duties and skills required.

Who we are:

Cherry Health Michigans largest Federally Qualified Health Center (FQHC) operates in six counties across the state is based in Grand Rapids. With a team of more than 800 health care professionals at 20 locations Cherry Health focuses on removing barriers expanding access and delivering comprehensive quality health care services to underserved communities regardless of an individuals insurance status or ability to pay. We provide primary care dental vision behavioral health pharmacy services substance abuse services residential re-entry services school-based health centers and more.

Our Mission:

Cherry Health improves the health and wellness of individuals by providing comprehensive primary and behavioral health care while encouraging access by those who are underserved.

Our Vision:

Our community will be healthier because we will seek out and welcome those who need our services. All will be treated as family with integrated coordinated care to improve health and personal well-being.

Our Values:

• Collaboration Support the Cherry Health mission by encouraging teamwork to accomplish organizational goals.
• Customer Service Serve internal and external customers in a welcoming manner with compassionate care.
• Innovation Embrace creativity to improve patient care and workplace efficiency while remaining curious and open to learning.
• Integrity Uphold the highest ethical standards by being honest and trustworthy.
• Professionalism Create a positive work environment where we care accountable for our decision our action and the results.

Benefits:

Cherry Health has excellent benefit offerings dependent on employment status. Check out a sample of the benefits available to our team members below!

• Loan repayment through the NHSC and Michigan State Loan Repayment Program for select roles
• Medical Dental and Vision Insurance for you and your family
• Generous Paid Time Off benefit 4 weeks per year for full time
• Paid holidays - 8 full day paid holidays (Including Black Friday!) and 2 half day paid holidays!
• 403(b) Retirement Savings Plan with generous employer match - $ for $ match up to 5%
• MET and MESP 529 Savings Plans
• Pet Insurance!
• Employee Assistance Program

Our policy is to offer all employees and applicants for employment equal opportunity without regard to race color religion gender national origin age disability genetic information marital status height weight sexual orientation gender identity or status as a covered veteran in accordance with applicable federal state and local laws or any other protected category.