Care Coordinator Registered Nurse - Remote in Michigan

About Us McLaren Health Care is a fully integrated health network committed to quality, evidence-based patient care with locations in Michigan and Indiana. The McLaren system includes 13 hospitals in Michigan, ambulatory surgery centers, imaging centers, a primary and specialty care physician network, commercial and Medicaid HMOs, home health, infusion and hospice providers, pharmacy services, a clinical laboratory network and a wholly owned medical malpractice insurance company. McLaren operates Michigan’s largest network of cancer centers and providers, anchored by the Karmanos Cancer Institute, one of only 53 National Cancer Institute-designated comprehensive cancer centers in the U.S. Care Coordinator Registered Nurse - Remote in Michigan Michigan, Flint NEW Nurse McLaren Medical Group 25007188 Position Summary: As an advocate for the patient, the RN care manager will assess, plan, implement, coordinate, monitor, and evaluate the options and services required to meet an individual’s health needs, using clinical and community resources to promote quality, cost effective outcomes. Integrates evidenced based clinical guidelines, preventive guidelines, and protocols, in the development of individualized care plans that are patient centric. Provides targeted interventions to avoid hospitalization and emergency room visits. Essential Functions and Responsibilities: 1. Provides telephonic and face-to-face comprehensive assessment and care management services to patients as part of an interdisciplinary team. 2. Uses multi-dimensional assessment skills, risk assessment and screening tools to target high risk and vulnerable populations. 3. Assesses over time the health care, educational, and psychosocial needs of the patient/caregiver. Uses standardized assessment tools such as depression screening, functionality, and health risk assessment. 4. 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. 5. Uses clinical judgment to determine level of care and collaborates with the PCP, patient and interdisciplinary team, including continuum of care settings and community. Required: • RN with a valid unrestricted Michigan license. • Three (3) years clinical nursing experience serving chronically ill patients and extensive knowledge of issues associated with chronic care and geriatrics. Preferred: • RN, BSN. • Three (3) years experience in a health plan or Physician Organization environment with care coordination, care management, and/or population health. • Telephonic care management experience. • Home care and/or hospice experience. • Complex Care Management course completion or CCM. Additional Information • Schedule: Full-time • Requisition ID: 25007188 • Daily Work Times: 8am-5pm • Hours Per Pay Period: 80 • On Call: No • Weekends: No McLaren Health Care is an Equal Opportunity Employer. Qualified applicants will receive consideration for employment without regard to race, color, religion, sexual orientation, gender identification, age, sex, marital status, national origin, disability, genetic information, height or weight, protected veteran or other classification protected by law. Apply tot his job