RN Home Based Primary Care Nurse

Care Manager

The care manager is responsible for a case load of 80-100 patients who are receiving home based primary care. Responsibilities include home visits, telephone contact with patients and support systems. CM's are part of the interdisciplinary team consisting of physicians, APP's, social workers, MA's and triage nurses.

Scope of Work

Plans and prioritizes care for individuals and population of patients, focusing on strategies that will promote optimal health within populations. Demonstrates expertise, current knowledge in nursing care and management of a caseload of patients of varying complexity and seeks to improve patient, family and health systems/community outcomes through the application of educational concepts/skills and preventive care in a managed care environment.

• Assesses internal and external referrals to identify patient/significant others' needs, level of intensity, insurance benefits and other patient resources.
• Develops plan of care and makes recommendations to PCPs, specialists and other members of the health care team regarding care management strategies, identifying strategies to maximize continuity of care across the continuum.
• Assesses the educational needs of patients, families and members of the health care team and develops and implements appropriate teaching strategies or makes appropriate referrals.
• Communicates and collaborates with patient/significant others/providers/payers to coordinate services that improve access to appropriate services across the continuum of care and which promotes optimal health in a cost-effective manner.
• Measures patient care outcomes, interprets reports and analyzes data trends for groups of patients.
• Documents patient data, plan, interventions and outcomes according to department guidelines.

Qualifications

• Required Bachelor's Degree or equivalent nursing or a healthcare related field (all departments except Corewell Health Ludington)BSN must be obtained within 7 years for those who start in this RN role on or after January 1, 2017 (Corewell Health Ludington Hospital)
• 2 years of relevant experience clinical nursing and or case management/managed care or related field Required
• 5 years of relevant experience clinical nursing and or case management/managed care or related field Preferred
• Registered Nurse (RN) - State of Michigan Upon Hire required
• Case Manager, Certified (CCM) - CCMC Commission for Case Manager Certification Upon Hire preferred
• Basic Life Support (BLS) - AHA American Heart Association Upon Hire required Or
• Basic Life Support (BLS) - ARC American Red Cross Upon Hire required