Job no: 713384
Work type: Support Staff
Pay Grade: 12
Major Administrative Unit / College: Msu Hci Clinical Services
Department: Msu Hci Clinical Services 40001137
Sub Area: AP- Professionals
Salary: Salary Commensurate with Experience
Location: East Lansing
Categories: Health Care Professional, Health Care Support, Administrative Professionals- AP, Full Time (90-100%), Union
Position Summary

• Identifies the targeted population within practice site(s), per primary care provider referral and registry reports.
• Assesses the health care, educational, and psychosocial needs of the patient/family using standardized assessment tools such as depression screening, functionality, and health risk assessment.
• Collaborates with the primary care provider, patient, and members of the health care team within the clinic, to assess patient, develop and implement an agreed upon plan.
• Provides self-management support and patient education to achieve optimal health and independence
• Implements evidence-based care, chronic disease protocols and guidelines.
• Identifies gaps in care and coordinates resolution of gaps for population management.
• Coordinates patient care by linking patients to resources; including community resources.
• Provides follow up with patient/family when patient transitions from one setting to another including: completes post hospital discharge calls, medication reconciliation, follow up appointments, symptom assessment, warning signs education, care coordination, discharge instructions review, and barrier problem-solving.
• Maintains required documentation for all care management activities.
• Works with practice and Physician Organization/Physician Health Organization (PO/PHO) leadership to continuously evaluate processes, identify problems, and propose/develop process improvement strategies to enhance the Patient Centered Medical Home.
• Reviews the current literature regarding effective engagement and communication strategies, care management strategies, and behavior change strategies and incorporates into clinical practice.
• Understands and implements appropriate chronic disease management strategies, protocols and guidelines.
• Collaborates with members of the health care team to empower patients to manage their chronic conditions. Serves in an expanded health care role to collaborate with Primary Care Physicians and patients to ensure the delivery of quality, efficient, patient centered, and cost-effective healthcare services.

Unit Specific Education/Experience/Skills

Knowledge equivalent to that which normally would be acquired by completion of a four-year college degree program in a clinical field; one to three years of related and progressively more responsible or expansive work experience in care management including chronic conditions, evidence-based guidelines, prevention, wellness, health risk assessment, and patient education; and/or experience with adult medicine and pediatric patients in primary care/ambulatory care, home health agency, skilled nursing facility, or hospital medical-surgical; knowledge of electronic medical records; or an equivalent combination of education and experience.

Desired Qualifications

BSN required

One year of experience in Care Management.

Equal Employment Opportunity Statement

All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, citizenship, age, disability or protected veteran status.

Required Application Materials

Cover letter

Resume

Proof of RN License in the state of Michigan.

Work Hours

Work hours are typically 8:00 a.m. – 5:00 p.m., but can vary as necessary to accommodate clinic operations.

Summary of Health Risks

Exposure to human blood, serum, tissue and other body fluids; and materials covered under Universal Precautions; TB risk or work within three (3) feet of patients in a health care setting; wear a respirator. Covid precautions.

Bidding eligibility ends on 06/22/2021 at 11:55 PM

Advertised: Jun 16, 2021 Eastern Daylight Time
Applications close: Jun 22, 2021 Eastern Daylight Time