Munson Medical Center Complex Care Coordinator - Grayling in Grayling, Michigan

Job Summary: Provides care management and care coordination for adult and pediatric patients with complex illness, in the primary care setting, under minimal supervision. Serves in an expanded health care role to collaborate with PCP, specialists, members of the health care team, and patients/families to ensure 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.

Manages a caseload of approximately 150 complex patients; of which 30 to 50 patients are actively followed by complex care manager. Team with Moderate risk care team for RN only roles. Provides targeted interventions to avoid hospitalization and emergency room visits. Coordinates care across settings and helps patient/families understand health care options. Infrequent, but possibility of home visits.

Minimum Requirements: Bachelor of Science in Nursing preferred, together with a current R.N. license to practice nursing in the State of Michigan. Previous experience in Care/Case Management preferred. Minimally, 3-5 years progressive experience in a clinical acute care setting or medical office setting with current experience relevant to patient population served. Individual must be detail oriented, have computer application experience as well as excellent written/oral communication skills. Knowledge of Medicare, Medicaid and commercial payer regulations preferred

Skills, Talents and Abilities: Must be able to work cooperatively as a member of a team, able to communicate effectively with patients and their families as well to all levels of the hospital staff. Must be flexible, self-motivated, interested in program development and capable of making independent decisions. Ability to be non-judgmental and work with those holding diverse opinions, religions and cultural values. Significant analytical ability is required; must be accurate, concise and detail oriented.

Age of Patients Served:

Cares for patients in the age category(s) checked below: No clinical contact with patients

x Neonate/Infant x Preschool x School Age x Adolescence x Adult x Geriatric

Position Accountabilities:

  1. Engages and collaborates with patients, families, inpatient multi-disciplinary staff, the primary care provider, and the community in care planning, delivery of care, and discharge on target populations. 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.

  2. Works with physician care team to identify the targeted populations within the hospital utilizing risk stratification process and target lists. Implements clinical interventions and protocols based on risk stratification and evidence-based clinical guidelines.

  3. Coordinates patient care through ongoing collaboration with PCP, patient/family, community, and other members of the health care team. Fosters a team approach and includes patient/family as active members of the team. Takes the lead in ensuring the continuity of care which extends beyond the practice boundaries.

  4. Excellent assessment skills: Displays excellent assessment experience and skills by utilizing evidence based practice knowledge and skilled intervention based on chronic disease models in order to effectively prioritize and complete comprehensive assessments and facilitate appropriate care coordination.

  5. Provides care coordination with patient/family/healthcare entities; case management with disease process surveillance, medical necessity and utilization; education on wellness, disease, and self-management; and resource coordination with the community.

  6. Performs other duties as assigned.