<p>POSITION SUMMARY:</p> <p>The RN Case Manager serves in an expanded healthcare role to collaborate with specialists, members of the healthcare team and patients/families to ensure the delivery of quality, efficient and cost effective healthcare services. Develops and assesses plan of care with patient/family, implements, monitors, and evaluates all options with the goal of optimizing patient's health status. Utilizes evidence based clinical guidelines, preventive guidelines and protocols to develop patient centered care plans.</p> <p>DUTIES AND RESPONSIBILITIES:</p> <ul> <li>Consults and communicates care objectives with primary care providers, specialists and community resources to aid patient in achieving healthcare goals. </li><li>Identifies the targeted population by referral from primary care provider, patient registries. </li><li>Assesses the healthcare, education and psychosocial needs of the patient/family. </li><li>Identifies and maintains relationships with referral and community resources. </li><li>Collaborates with primary care provider, patient, the healthcare team as well as community resources. </li><li>Develops an individualized plan of care with targeted interventions, monitors patient and family's response to plan of care and adjusts plan of care as needed. </li><li>Provides patient with self-management tools/support to build ability for self-care. </li><li>Maintains required documentation for all case management activities. </li><li>Reviews current literature regarding engagement strategies, communication strategies and incorporates best practices into clinical setting. </li><li>Maintain records and enter information into database as required. </li><li>Assist team in defining and working to identified quality indicators, ie: HEDIS/UDS, North Star, PCI initiative, etc. </li><li>Attends required in-service and departmental meetings. </li><li>Follow up on hospital admissions and ED visits daily. </li><li>Works with and manages our most complex patients to assure timely access to care and following treatment plan. </li><li>Other duties as assigned </li></ul> <p>TYPICAL WORKING CONDITIONS:</p> <ul> <li>The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. </li><li>Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. </li><li>Must be able to work in stressful environment. </li><li>This job operates in a professional office environment. This role uses standard office equipment such as computers, phones, photocopiers, filing cabinets and fax machines. </li><li>While performing the duties of this Job, the employee is frequently exposed to airborne particles within a health care facility or home setting. </li><li>The noise level in the work environment is usually quiet but occasionally may become disruptive while working with a client. </li></ul> <p>TYPICAL PHYSICAL DEMANDS:</p> <ul> <li>The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. </li><li>Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. </li><li>While performing the duties of this Job, the employee is regularly required to use hands to finger, handle, or feel </li><li>Must be able to communicate by talking or listening to hear conversational voices. </li><li>The employee is frequently required to stand, climb stairs, walk and sit. </li><li>Withstand frequent lifting, stretching and other physical exertion. </li><li>Ability to manage exposure to patient elements: vascular access procedures, treatment of minor/major injuries, disposing of contaminated waste, cleaning and disinfecting equipment, handling of contaminated sharps. </li><li>The employee is occasionally required to stoop and kneel. </li><li>The employee must occasionally lift and/or move up to 50 pounds. Specific vision abilities required by this job include close vision, peripheral vision and ability to adjust focus. </li></ul> <p>QUALIFICATIONS:</p> <ul> <li>Basic Life Support/CPR training </li><li>Demonstrates customer focused interpersonal skills to interact in an effective manner with practitioners, interdisciplinary health care team, community agencies, patients/families with diverse opinions, values as well as religious and cultural beliefs. </li><li>Demonstrates excellent written, verbal/listening skills. </li><li>Demonstrates positive relationship building skills and critical analysis skills. </li><li>Demonstrates ability to work autonomously and be accountable for practice. </li><li>Demonstrates ability to influence to influence and negotiate individual and group decision. </li><li>Demonstrates ability to function in a fluid, dynamic changing environment. </li></ul> <p>EDUCATION/EXPERIENCE/CERTIFICATIONS/LICENSES:</p> <ul> <li>Associate Degree in Nursing, required. Bachelor's Degree in Nursing, preferred. </li><li>Minimum of one year experience with adult/peds medicine in primary care/ambulatory care, home health agency, skilled nursing facility or hospital medical-surgical setting within the past five years or an equivalent combination of education, and experience to perform the duties and responsibilities of the job. </li><li>Licensed as an RN in the state of Michigan. </li><li>Certification in Case Management preferred. </li></ul> <p>Family Health Center has the right to modify the duties and functions of the job description based on the needs of the organization.</p>