RN Care Manager - Trinity Health CHF Clinic - Muskegon

• Trinity Health Congestive Heart Failure Clinic (CHF) - Muskegon, Michigan
• Monday - Friday, Business hours
• On site position embedded in the clinic, one day a week remote work option.
• Amazing team to work with!

POSITION SUMMARY: The RN Care Manager is a professional nurse who collaborates with physicians, facilities, health care team members and patient/families to manage chronic conditions/complex illness and coordinate care for specific patient populations across the continuum and between care settings as an important member of the Patient Centered Medical Home team.

What the RN Care Manager will:

• Participate and engage their patients in the assessment, planning, monitoring and evaluation of the ongoing care for chronic condition/complex illness management.
• Establish plans of care including patient education, self-management, care coordination, and coordinating resources for effective, efficient and appropriate patient care.
• Provide ongoing monitoring and evaluation of patient outcomes.
• In addition to these responsibilities, the RN Care Manager also performs the duties of population health management, which includes risk stratification to identify high and rising-risk patients. This also includes care coordination and management, patient engagement, and addressing SIOH needs in proactive efforts to improve outcomes, reduce cost, and improve health equity.
• The RN Care Manager will assist patients in optimizing their health status; providing interventions designed to avoid hospitalization and emergency room visits.

What the RN Care Manager will need:

• Graduate of an accredited school of nursing. Bachelor of Science degree in Nursing required. Master's Degree in Nursing (or actively pursuing Master's Degree in Nursing) preferred. Recent case management experience preferred.
• Current licensure to practice nursing in Michigan.
• One year of experience in Case Management preferred and three years of clinical experience in nursing required.