Support the patient-centered medical home (PCMH) by working with patients, families, providers, and other community resources promoting timely access to needed care and ensure continuity of care coordination.
Assist patients, families, and caregivers to develop a self-care management plan with their providers to monitor and treat their conditions.
Evaluate care for specific patient populations using the process of assessment, planning, implementation and evaluation.
Data mines patients, utilizing disease registry and EHR system and participate in population management activities as directed by the Practice.
Track revenue and quality impacts of care management services.
Graduate of a school of nursing.
Bachelor Degree in Nursing or Healthcare Management preferred.
Prefer three to five years' with duties in leading care coordination, or the equivalent.
Experience in inpatient and outpatient care, including health coaching, motivational interviewing and disease management preferred.
Current license as a Registered Nurse in the State of Michigan. Certified Care Manager preferred.
Participation in mandatory annual certification, and educational programs for improvement of self to maintain competency.