Provides care management and care coordination for adult and medicine/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.
MAJOR DUTIES AND RESPONSIBILITIES:
* Identifies the targeted high risk population within practice site(s) per PCP referral, risk stratification, and patient lists. Includes patients with repeated social and/or health crises.
* Assesses over time the health care, educational, and psychosocial needs of the patient/family. Uses standardized assessment tools such as depression screening, functionality, and health risk assessment. Provides assessment and care through face-to-face encounters, group visits and telehealth encounters.
* Collaborates with PCP, patient, and members of the health care 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.
* Implements 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, patient/family, community, and other members of the health care team. Fosters a 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, teach warning signs, review discharge instructions, coordination of care, and problem solve barriers.
* Demonstrates excellent written, verbal, and listening communication skills, positive relationship building skills, and critical analysis skills.
* Maintains required documentation for all care management activities.
* Works with practice and Ambulatory Care Unit 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.
Nursing Specific Info
Required qualifications must be met by the candidate in order to be interviewed and considered for the position. Posting may be filled after the initial 5-day posting period.
Salary & Nursing Framework Level:
This UMPNC RN posting is posted as Nursing Framework REG NURSE - LEVEL C (B INC).
Actual Nursing Framework LEVEL and salary will be determined at time of hire.
Nursing Framework levels range from Level A to Level E.
Applicants who have left the UMPNC bargaining unit must include on their resume dates of past employment including months and years of service along with effort. Positions less than 20 hours/week may be combined.
If you have questions regarding this posting or would like assistance with nursing opportunities please contact Nurse Recruitment at (734) 936-5183.
Current Michigan license as a Registered Nurse
Three years of recent experience with adult medicine patients in primary care/ambulatory care or home health agency
Knowledge 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
Demonstrates excellent communication--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
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.
Demonstrated partnership and leadership with members of the health care team in current chronic care initiatives as validated by performance evaluations and references
Recent experience with pediatric patients
Care management experience
Completion of self-management support training
Bachelor's degree in Nursing or higher
Certification as a Case Manager by the Case Management Society of America
Experience as participant in continuous quality improvement
Shift/Hours/Days: Monday through Friday; Day Shift, with variable start times with potential evenings and weekend days with expansion.
* 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 checks on all job candidates upon acceptance of a contingent offer and may use a third party administrator to conduct background checks. Background checks will be performed in compliance with the Fair Credit Reporting Act.
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.
Michigan Medicine seeks to recruit and retain a diverse workforce as a reflection of our commitment to serve the diverse people of Michigan and to maintain the excellence of the University. We welcome applications from anyone who would bring additional dimensions to the University’s research, teaching, and clinical mission, including women, members of minority groups, protected veterans, and individuals with disabilities. The Department of Nursing, like the University of Michigan as a whole, is committed to a policy of nondiscrimination and equal opportunity for all persons and will not discriminate against any individual because of race, color, national origin, age, marital status, sex, sexual orientation, gender identity, gender expression, disability, religion, height, weight, or veteran status.
U-M EEO/AA Statement
The University of Michigan is an equal opportunity/affirmative action employer.