• Actively seeks to engage moderate and high risk patients in the care management program through proactive telephonic outreach, practice and home based encounters.
• Conduct comprehensive assessments (in-home, in primary care practice or telephonically) to identify the patient’s needs and goals, health behaviors, functional and/or cognitive impairment, psychosocial issues, environment, and areas of risk that may impact the patient’s adherence to the treatment plan.
• In collaboration with the multi-disciplinary care team, develops an individualized care plan and intervention strategies to meet the patients needs and focused on improved clinical outcomes and patient satisfaction. The RN Care Manager will monitor the care plan for effectiveness, review with the primary care physician, and modify as needed to optimize the patient’s progress and well-being.
• Establish and support the patient’s self- management goals
• Provide education on management of chronic conditions and enhances the patient’s self-efficacy to prevent progression or exacerbation of chronic illness and promote healthy behavior change.
• Coordinate care transitions and monitoring of high risk patients following hospital and sub-acute discharges to ensure timely follow-up with primary care and prevent readmissions.
• Facilitate discussions with the patient and caregiver regarding advanced directives and palliative care.
• Align resources with the patient including referrals to other disciplines of the care management team, home care, community resources, and other healthcare providers.
• Actively participate in multi-disciplinary team conferences.
• Maintain timely and complete medical record documentation and billing of all care management encounters.
• Work with the practice and physician organization to continuously evaluate processes and develop improvements to advance the care management program.
• Serve as a positive ambassador for United Physicians in the practices, and support initiatives leading to practice transformation.
• Adhere to the scope of practice for Registered Nurses per state regulatory guidelines.
• Respect confidentiality of all persons and follows state, federal and organization policies and procedures
• Effectively participate in various internal committees and performs other duties as requested by management.
• Evaluate patients for needed services (HEDIS metrics) assist in closing “gaps” for needed health services (preventative and condition specific)
• Miscellaneous duties and projects as assigned.
30600 Telegraph Rd., Ste 4000
Bingham Farms, MI 48025