INTERCARE COMMUNITY HEALTH NETWORK
Location
Park Township, Michigan
Salary
$70,000 / YEAR
Provides holistic healthcare and care management for high-risk patients with multiple chronic conditions in an ambulatory setting. Responsibilities include population health management, patient education, and collaborating with healthcare teams to achieve health goals.
Requires a current Registered Nurse (RN) license in Michigan and BLS certification within 90 days. Preference is given to candidates with at least two years of ambulatory or hospital nursing experience and care management expertise.
Current Registered Nurse (RN) License in the State of Michigan Minimum of two years of ambulatory and/or hospital nursing experience preferred, care management experience preferred BLS Certification, to be completed within 90 days Primary Accountability Serves as a member of the care team providing high quality, holistic healthcare to patients with multiple chronic conditions [high risk patients] through a client-centered approach. Responsible for providing care management to complex patients, population health management and for assisting the healthcare provider in an ambulatory care setting. Description of Primary
Provides ongoing Population Health Management Monitors evidence-based clinical indicators to assess progress toward better health and shares these with the patient/families to initiate disease management protocols in collaboration with provider, develops/revises/evaluates process standards and clinical guidelines Provides patient education and identifies patient teaching needs related to disease management including: diet, exercise, and medications Utilizes patient registries and lists to identify at-risk patients who would benefit from care management, particularly patients with identified risk stratification level of 7 and 9 Performs or assures completion / documentation of a comprehensive patient assessment: medical, functional, cognitive, affective, psychosocial, nutritional and environmental Monitors the patient, assessing progress on self-management goals, and if current goals met, guides the patient to set new goals. Identifies barriers to care and works to help the patient problem-solve to overcome them Provides medication management and adherence education within the scope of care management Manages care of patients through collaboration with members of the health care team and other health professionals in order to make decisions about treatment and assist the patient in attaining health goals. Qualifications Requirements Professional and Technical Knowledge Displays compassionate, ethical and professional demeanor Communicates effectively with patients and family members involved in their care Able to use computers and Microsoft Office efficiently Communication Skills Possesses a communication style to convey complex concepts in a clear effective manner Possesses excellent cross cultural communication skills and the ability to communicate to staff members at all levels Physical Demands Job duties are performed in the typical office environment of the organization, which requires ordinary ambulatory skills sufficient to visit other locations. The environmental factors and/or physical requirements of this position include the following: Ability to stand, walk, stoop, kneel, crouch, frequently sit, and lift up to 25 lbs Requires good hand-eye coordination, reach with arms & hands, and finger dexterity, including ability to grasp, and manipulate (using keyboard, office equipment) Visual acuity to use keyboard, operate office equipment, and read printed material and regularly required to talk and hear Able to hear and communicate clearly with clients and staff on telephone and in person
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