· 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.