Case Manager RN - Shattuck Rd; Saginaw

Summary

Provides care management and care coordination for adult and pediatric patients with complex illness in the primary care setting under minimal supervision. Works with both moderate and high risk patients to optimize control of chronic conditions and prevent/minimize long term complications. Coordinates care across settings and helps patient/families understand health care options. In partnership with the primary care practice leadership team, the Care Manager leads care management within the team.

The Case Manager (CM) accomplishes this through process improvement, workflow redesign, providing assistance with training, and delegating to other members of the team. The CM serves in an expanded health care role to collaborate with specialists, members of the health care team, and patients/families ensuring the delivery of quality, efficient, and cost‑effective health care services. Assesses plans, implements, coordinates, monitors and evaluates all options and services with the goal of optimizing the patient's health status.

Integrates evidence‑based clinical guidelines, preventive guidelines, and protocols, in the development of individualized care plans that are patient‑centric, promoting quality and efficiency in the delivery of health care.

• (25%) Collaborates with primary care provider (PCP), patient, and members of the health care team, including continuum of care settings and community. Responsible for developing a comprehensive individualized plan of care and targeted interventions. Continually monitors patient/family response to plan of care, and revises the care plan as indicated.
• (20%) Identifies the targeted high‑risk population within practice site(s) per PCP referral, risk stratification, and patient lists. Includes patients with repeated social and/or health crises.
• (20%) Implements clinical interventions and protocols based on risk stratification and evidence‑based clinical guidelines.
• (15%) Assesses over time the health care, educational, and psycho‑social needs of the patient/family. Uses standardized assessment tools such as depression screening, functionality, and health risk assessment.
• (10%) Provides patient self‑management support with a focus on empowering the patient/family to build capacity for self‑care.
• (10%) Implements systems of care that facilitate close monitoring of high‑risk patients to prevent and/or intervene early during acute exacerbations.

OTHER

DUTIES AND RESPONSIBILITIES:

• Demonstrates an understanding of care management, high‑risk management, transitions of care, complex and chronic conditions, post‑acute care options, and community management standards.
• Provides care management and coordination within the timeframe provided with the CM Program guidelines and the care plans. Conducts clinical assessments. Develops, monitors, and updates a person‑centered care plan. Actively secures the necessary authorizations for the services that are the responsibility of the organization to ensure the member's timely access to the services identified in the person‑centered care plan.
• Able to adhere to communicated care management productivity metrics, including caseload, engagement volume, and time to closure. Also adheres to quality standards for care management per policy, including appropriate cases opened, comprehensive documentation, actionable care plans, and appropriate cases closed in a timely fashion.
• Ensures the member receives the full scope of care coordination services, including comprehensive assessment completion as required.
• Coordinates across the interdisciplinary care team, including transitions of care to ensure safety and quality of clinical care. Demonstrates participation in multidisciplinary team rounds, as appropriate, to address utilization/resources and progression of care issues. Assists in developing and implementing an improvement plan to address issues. Implements goals and objectives that support overall strategic plans of the organization. Conducts incident reporting as required.
• Identifies gaps in care and takes action as necessary to close gaps in care. Outreaches to patients to engage in care management, coordination, and…