Title:

RN Care Manager/Patient Educator Starting pay range: $72,000 per year depending on experience and qualifications.

Supervisor:

Chief Operating Officer FLSA Status:

Salary -

Exempt/ Full-time Location:

Isabella Citizens for Health, Inc.

Job Summary:

The RN Care Manager/Patient Educator works as part of an interdisciplinary care team to provide a range of nursing services including direct patient care, care management, care coordination and patient education. The RN position serves to manage outpatient health care delivery and quality improvement activities for patients to support providers in delivering quality care services and to work collaboratively with other health care teams members. The RN's clinical practice will be within their scope of licensure and under the clinical direction of the Providers.

Essential Functions and Responsibilities:

Works collaboratively within the interdisciplinary care team structure to facilitate efficient processes necessary to support clinical operations of patient care. Follows up with and facilitates individual patient care plans to assure continuity of care and lower ED utilization or hospital readmission. Proactively identifies and stratifies patients appropriate for care management services, using established Center protocols and risk criteria, to support value-based care program requirements and Patient-Centered Medical Home (PCMH) standards. Processes and tracks patient referrals for homecare, hospice and palliative care. Provides education and coaching to patients with new or complex disease processes, and on health maintenance and disease prevention. Assists with assigned care management responsibilities, including care coordination, follow-up communication, and documentation to support quality outcomes and continuity of care. Utilizes the Center's EMR, population health tool, patient portal, digital messaging system, and other applicable IT systems to accurately and timely document patient care, communicate with the care team, and review and run reports. Utilizes information exchange networks and health care portals to seek out patient care utilization, reports, results and for patient care tracking purposes. Develops a positive relationship with area medical providers, hospitals, skilled nursing facilities, and other health service organizations to ensure access to care and transition of care for Center patients. Provides direct patient care under the supervision of the Provider. Administers injections and vaccines as requested. Performs staple removals as requested by a Provider. Examines incision sites as requested by a Provider. Performs blood pressure checks. Follows protocols for various patient appointment types including following standing orders. Communicates effectively with patients, family and the entire health care team. Appropriately documents all interventions in patient care. Accepts a key role in supporting the quality care and process improvement initiatives of the Center. Recognizes and reacts appropriately to an urgent or emergent situation. Actively supports and participates in the organizational performance improvement program. Participates in activities promoting professional growth and development. Fosters a culture oriented to achieve the Center's mission to serve the underserved in an obstetrics setting while maximizing the use of resources. Other duties as requested.

Note:

This job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for the job. Duties, responsibilities and activities may change at any time with or without notice.

Qualifications:

Required Licensed as a Registered Nurse in the State of Michigan. Must maintain a valid driver's license. Must be able to successfully complete and pass a criminal background check and drug screening. Current BLS. Preferred Prior clinical nursing experience in a obstetrics and/or primary care setting. Experience providing direct one-on-one or group patient education. Experience in care coordination and chronic care management. Experience and knowledge of the Patient Centered Medical Home care delivery model.

Position Specific Expectations:

Must be a self-starter and work with little or no supervision. Must have the ability to maintain positive interpersonal relationships with patients, physicians, other employees and the general public; and work well in a team-oriented environment. Must be willing and able to utilize software systems and health information technology. Ability to maintain the confidentiality of records, documents or discussions related to clinic and departmental functions. Attendance is an essential element of this position. Employee Benefits Isabella Citizens for Health offers a competitive compensation and benefit package including paid time off, medical/dental/RX/vision insurance, short-term disability, life insurance and an employer match 403(b) retirement plan. Isabella Citizens for Health is an approved site for loan repayment under the National Health Service Corps. This health center is a Health Center Program grantee under 42 U.S.C. 254b. and a deemed Public Health Service employee under 42 U.S.C. 233(g)-(n).

Job Type:

Full-time Pay:

From $72,000.00 per year

Benefits:

403(b) matching Dental insurance Employee assistance program Flexible spending account Health insurance Life insurance Paid time off Retirement plan Tuition reimbursement Vision insurance Application Question(s): A cover letter is required as well as a resume.

Work Location:

In person