RN Care Manager

3 weeks ago

Clarkston, United States Clarkston Medical Group Full time

The Nurse Care Manager at Clarkston Medical Group will be part of the Care Management Department. The primary responsibility for the Nurse Care Manager is to work with the patient, caregiver, PCP and outside agencies to deliver high quality care to patients living in a home setting. This may include coordinating DME, medication refills, requesting progress notes from various specialists, or having regular conversations with the patient/caregiver.

The Nurse Care Manager will:

  • Receive and respond to inbound patient calls and secure patient messages
  • Perform appropriate triage and escalation of routine and urgent patient calls
  • Assess, identify, and close clinical and non-clinical gaps in care
  • Create and manage plans of care for patients identified as appropriate for services
  • Manage actions identified by the patient care plan
  • Conduct proactive telephonic or video consultations to screen for new issues, reassess the patient, update the care plan, and evaluate progress toward the goals of the care plan
  • Evaluate changes in patient-reported symptoms and conduct additional triage and screening as needed to determine next steps
  • Support the safe transfer of the patient to their PCP, ED, or hospital when clinically necessary
  • Educate patients and families on treatment options, including cost, efficacy, and side effects
  • Provide and deliver disease and symptom specific patient education
  • Coordinate the ordering and delivery of clinical and community services, including home health, DME, hospice, medication delivery, and other community resources required to maintain the patient’s health status and meet their care goals
  • When appropriate, discuss and document the patient’s wishes using Advanced Care Planning documents and state specific POST/POLST forms

QUALIFICATIONS:

  • Active, unrestricted RN license in Michigan
  • A minimum of 2 years of related clinical experience, preferably in care management, home care, hospice, or inpatient care
  • Proficient in EMR use, keyboarding, Microsoft Office – including Excel

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