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Case Manager- ED/IP/Chronic Care Nurse Navigator

Company: HAMILTON COMMUNITY HEALTH NETWORK
Location: Flint
Posted on: June 25, 2022

Job Description:

Job DetailsJob LocationAdministration - Flint, MIPosition TypeFull TimeEducation Level2 Year DegreeTravel PercentageNoneJob ShiftAnyJob CategoryHealth CarePosition Summary This position is responsible for providing case management and outreach services to patients in alignment with the goals of the ED/IP/Chronic Care Navigation and Readmission Diversion program.General responsibilitiesUse Health Information Exchange (Azara) to implement a Utilization Review process to identify patients who are in the hospital or visited the ED or have over-utilized the ED.Follow-up with patients to establish a primary care provider within the HCHN system and assure a follow-up visit following discharge.Provides Transition of Care collaboration between health care organizations and documents services.Identify patients with chronic care conditions to be managed through an established chronic care model at HCHN and assist in closing gaps in care.Completes medical assessment/history and fall assessment for each client including medication reconciliation and develops a documented plan of care for each clientProvides health education related to the condition and assists with the coordination of care for patients as directed by the healthcare providers and related to the patient's needs.Analyzes patient/family assessment data with respect to physical, psychosocial, educational, and all other needs.Completes an assessment of patient/family needs with respect to physical, psychosocial, educational, and all other needs.Evaluate patients response to care through observation.Assesses patients with respect to specialized needs, social determinants of health and assists with navigation through the health care system.Assist patients with development and follow-through for self-management goals.Assists patients entering substance abuse or other chronic care maintenance programs.Serves as a resource for the health team, patient, and family.Advises and makes recommendations to providers, patients, and families regarding the availability of resources and coverage locate the resources, and arrange for the provision of cost-effective services for patients.Assesses patients resource status and seeks out alternatives when coverage is not available.Ensures referrals to the CHW, Insurance navigator, or DHS worker for patients that are eligible for state funding or programming.Maintains a panel of patients served that includes all support services and efforts made to resolve issues of care.Prepares reports for contacts and navigation effortsOther duties as assigned.Education and/or ExperienceNursing degree from an accredited school of nursing or a bachelors degree in social work, sociology, or psychology, or related field is required.Current State of Michigan nursing licenseMinimum of two (2) years professional experience CPR certificationTwo years of case management experience preferred.QualificationsTo perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.Excellent interpersonal and customer service skills, to effectively and tactfully deal with a diverse group of patients, staff, customers, and community groups.Ability to maintain confidentiality in all matters.Flexible, with the ability to work independently and with minimal guidance. Strong oral and written communication skills. Ability to type 40 wpm.General computer proficiency.Ability to communicate effectively with diverse populations.Physical Demands The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.While performing the duties of this job, the employee is regularly required to talk or hear. The employee may be required to stand, walk, sit for long periods of time; use hands to handle or feel; reach with hands and arms; and stoop, kneel, or crouch. The employee must occasionally lift and/or move up to 25 pounds. Specific vision requirements include the ability to see at close range. At times, may require more than 40 hours per week to perform the essential duties of the position. Fine hand manipulation (keyboarding).Travel between sites using own vehicle.Work Environment The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Internal office space. The noise level in the work environment is usually moderate.May be exposed to communicable diseases.

Keywords: HAMILTON COMMUNITY HEALTH NETWORK, Flint , Case Manager- ED/IP/Chronic Care Nurse Navigator, Healthcare , Flint, Michigan

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