Trinity Health RN Care Manager CPC+ Program in Lake Orion, Michigan

Job Summary

The Outpatient- Based Care Coordinator coordinates the care of patients participating in population health contracts requiring care coordination for chronic disease across the continuum of care. The goals of the Care Coordinator are to help patients at the top tier of health risk to navigate throughout the care continuum and achieve their highest level of wellness, learn to live with or recover from illness, to optimize their care capabilities and to support their right to make choices. The Care Coordinator assesses individual member health needs utilizing a risk stratification process, develops individualized care plans, facilitate/implements/coordinates appropriate health services, monitors and evaluates health services and outcomes and document case coordination services.

Essential Functions and Responsibilities

Conducts and documents telephonic or on-site concurrent reviews to maintain utilization appropriateness of inpatient hospital stays, hospice, skilled nursing facility and home care, using established criteria. Practices motivational interviewing with patients along with adhering to competencies in identifying social determinants of health impacting the patient's care and experience. This includes planning interventions to ensure that the patient receives the most cost-effective services and/or treatment in the most appropriate setting throughout the continuum of care.

Identifies appropriate patients for care coordination services through available tools and PRISM risk stratification process. Completes initial comprehensive health assessment of the member’s physical, psychological, social, environmental, financial status and ability to function.

Develops and maintains documentation of individual care coordination alternative treatment plans based on patient's health assessment. Acts in the role of liaison between the patient, and the primary care physician (PCP). Maintains regular contact with the patient’s PCP. Provides education to patients and providers regarding population health contracting requirements. Advocates on the behalf of the patient to identify the most appropriate institutional or community resources and assists in closing the gaps. Reassesses social determinants of health with a focus on the patient’s family support system at appropriate intervals. Provides chronic care education for the patient and their support system on management of their disease. Periodically assesses the patient’s status and assigns the appropriate acuity level for how closely to follow the patient or if the patient has no further needs and should be discharged from care management. Participates in addressing quality issues. Actively supports patient satisfaction initiatives. Actively supports population health initiatives and support process improvement initiatives. Demonstrates effective team behavior and leadership. Supports other team members and works to support achievement of Population Health objectives. Maintains a working knowledge of population health care management practices and modalities for ambulatory care for chronic disease patients. Also, applicable Federal, State and local laws and regulations, Trinity Health’s Organizational Integrity Program, Standards of Conduct, as well as other policies and procedures in order to ensure adherence in a manner that reflects honest, ethical and professional behavior. Uses departmental resources in a cost effective manner and manages own work activities efficiently and effectively. Demonstrates initiative and seeks opportunities to enhance operating performance. Supports, or participates in a variety of committees, teams or groups as needed by current clinically integrated network (CIN) goals. Performs other duties as assigned.

This position does provide direct patient care in an ambulatory setting. Patient care is provided to all age groups (birth & above).

Job Requirements

A. Education, Experience, Certification and Licensure

  1. BSN Required

  2. Basic Life Support (BLS) for the Healthcare Provider certified or obtained within three (3) months of date of hire

  3. Valid, unrestricted license in the state of Michigan as a Registered Nurse

  4. Graduate from an accredited program in professional nursing

  5. ANCC (American Nurses Credentialing Center) Certification required.

  6. Five (5) years clinical experience

  7. Case Management certification is strongly desired. Candidates with home health experience also preferred

B. Special Skills

  1. Requires a high degree of knowledge, competence and skill which includes, but is not limited to:

 Relevant laws and regulatory requirements

 Understands care management theory basis; has sound clinical and cost analysis skills.

 Ambulatory Care Settings

 Population Health

 Clinical admission and discharge criteria

 Computer knowledge necessary for effective utilization of hospital and office based systems

 The ability to work in and facilitate the work of teams

 A working knowledge of available community resources or willingness to learn

 Ability to be non-judgmental regarding living and health-related decisions

 Ability to work with members and families with diverse opinions and diverse religious and cultural ideas and values.

 Ability to work autonomously with little direction and be directly accountable.

C. Demands

  1. Physical:

i. Standing, lifting, walking, reaching and the like throughout the working day.

  1. Special:

i. Ability to cope with stress, pressure, change and long hours as required.

ii. Ability to set and organize own work priorities, and adapt to them as they change frequently.


Job Number: 00107986

Location: Lake Orion, MI

Organization Name: Saint Joseph Mercy Health System

Facility: SJSEMI - Lake Orion IM/Peds

Employment Type: Full time

Shift: Day Shift

Hours: 40