Job Description

Registered Nurse Case Manager

The ideal candidate is a dedicated and compassionate Nurse with a strong emphasis on transitioning care. In this role, you will play a pivotal role in ensuring seamless transitions for patients between different healthcare settings, ultimately improving patient outcomes and experiences. Your expertise will be instrumental in coordinating, advocating, and facilitating the transfer of care across various phases of a patient's healthcare journey.

Responsibilities

The duties and responsibilities of the Nurse Clinician (RN) shall all be performed within the nursing scope of practice, and will include, but are not limited to:

• Care Transition Coordination: Collaborate with interdisciplinary teams, including physicians, nurses and other healthcare professionals, to assess patient needs and develop comprehensive transition plan. Coordinate the smooth transfer of patients from hospital to home, or infusion center(s) or other appropriate settings. Maintain accurate medical records.
• Patient Assessment: Conduct thorough assessments of patients' medical conditions, psychosocial factors, and support systems to determine appropriate care transitions. Develop tailored care plans that address patients' unique needs and preferences. Assist patient’s in navigating their healthcare benefits
• Communication and Education: Educate patients and their families about the care transition process, including medication management, follow-up appointments, and self-care strategies. Maintain open lines of communication among all stakeholders to ensure a smooth transition process. Implement interventions, utilizing appropriate judgement and creativity to resolve issues.
• Advocacy: Advocate for patients' rights and preferences during care transitions. Collaborate with healthcare providers to ensure that patients' individual goals and values are considered in the transition plan.
• Collaboration: Coordinate with hospitals, primary care providers, specialists, and community resources to ensure a coordinated transition process. Facilitate the exchange of essential patient information to support continuity of care.
• Risk Management: Identify potential risks associated with care transitions, such as medication discrepancies or lack of follow-up. Develop strategies to mitigate these risks and ensure patient safety.
• Documentation: Maintain accurate and comprehensive documentation of care transition plans, assessments, interventions, and outcomes. Ensure compliance with regulatory standards and organizational policies.
• Quality Improvement: Participate in quality improvement initiatives to enhance the effectiveness and efficiency of care transition processes. Collect and analyze data to identify areas for improvement.
• Other duties as assigned.

Qualifications

• Registered Nurse (RN) License: Current and valid RN license in Michigan
• Education: Bachelor of Science in Nursing (BSN) from an accredited institution. Master's degree in Nursing or related field is preferred.
• Case Management Certification: Certification in Case Management (CCM) or equivalent is desirable.
• Clinical Experience: Minimum of 2 years of clinical experience as a registered nurse, with a focus on care coordination and transition management.
• Case Management Expertise: Strong understanding of case management principles, care coordination processes, and best practices for transitioning care.
• Communication Skills: Excellent verbal and written communication skills. Ability to convey complex medical information in a clear and concise manner.
• Critical Thinking: Strong analytical and critical thinking abilities to assess patient needs, identify potential issues, and develop effective solutions.
• Empathy and Compassion: A compassionate approach to patient care, with the ability to establish rapport and build trusting relationships with patients and families.

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