Description:
Become part of a Migrant and Community Health Center, where you will:
Have a passionate purpose.
Do worthwhile work.
Make a difference in people’s lives.
At InterCare, you’ll find a rewarding and challenging work environment and a competitive compensation and benefits package which includes: vacation/personal paid time off, sick time, 10 paid holidays, tuition reimbursement program, medical, prescription, dental, vision, life insurance, and short term and long-term disability insurance.
At InterCare Community Health Network, we believe all people have the right to equal access to quality health care.
Primary Accountability
Serves as a member of the care team providing high quality, holistic healthcare to patients with multiple chronic conditions [high risk patients] through a client-centered approach.
Responsible for providing care management to complex patients, population health management and for assisting the healthcare provider in an ambulatory care setting.
Description of Primary Duties & Responsibilities
Provides ongoing Population Health Management
Monitors evidence-based clinical indicators to assess progress toward better health and shares these with the patient/families to initiate disease management protocols in collaboration with provider, develops/revises/evaluates process standards and clinical guidelines
Provides patient education and identifies patient teaching needs related to disease management including: diet, exercise, and medications
Utilizes patient registries and lists to identify at-risk patients who would benefit from care management, particularly patients with identified risk stratification level of 7 and 9
Performs or assures completion / documentation of a comprehensive patient assessment: medical, functional, cognitive, affective, psychosocial, nutritional and environmental
Monitors the patient, assessing progress on self-management goals, and if current goals met, guides the patient to set new goals.
Identifies barriers to care and works to help the patient problem-solve to overcome them
Provides medication management and adherence education within the scope of care management
Manages care of patients through collaboration with members of the health care team and other health professionals in order to make decisions about treatment and assist the patient in attaining health goals.
Requirements:
Professional and Technical Knowledge
Minimum of two years of ambulatory and/or hospital nursing experience preferred, care management experience preferred
Current RN license in the State of Michigan
BLS Certification, to be completed within 90 days
Displays compassionate, ethical and professional demeanor
Communicates effectively with patients and family members involved in their care
Able to use computers and Microsoft Office efficiently
Communication Skills
Possesses a communication style to convey complex concepts in a clear effective manner
Possesses excellent cross cultural communication skills and the ability to communicate to staff members at all levels
Physical Demands
Job duties are performed in the typical office environment of the organization, which requires ordinary ambulatory skills sufficient to visit other locations.
The environmental factors and/or physical requirements of this position include the following:
Ability to stand, walk, stoop, kneel, crouch, frequently sit, and lift up to 25 lbs
Requires good hand-eye coordination, reach with arms & hands, and finger dexterity, including ability to grasp, and manipulate (using keyboard, office equipment)
Visual acuity to use keyboard, operate office equipment, and read printed material and regularly required to talk and hear
Able to hear and communicate clearly with clients and staff on telephone and in person
Whatsapp
