Job Description

Job Summary

Serves as a population health subject mater expert in the practice. Plans and prioritizes care for individuals and population of patients, focusing on strategies that will promote optimal health within populations and directs patients to the right care team member at the right time. Demonstrates expertise, current knowledge in nursing care and management of a sub population of patients of varying complexity and seeks to improve patient, family and health systems / community outcomes through the application of educational concepts / skills and preventive care in a managed care environment.

Essential Functions

• Assesses patients within the practice (inpatient and outpatient) to identify patient/significant others\xe2\x80\x99 needs, level of intensity, insurance benefits and other patient resources while directing the patients to the right level of care within the office.
• Develops plan of care focused on lifestyle management, managing many aspects of high value annual wellness visits, and coordinating shared medical appointments and makes recommendations to PCPs, specialists and other members of the health care team regarding care management strategies, identifying strategies to maximize continuity of care across the continuum.
• Triage and direct patient to the appropriate care team member to meet the patient needs. Assesses the educational needs of patients, families and members of the health care team and develops and implements appropriate teaching strategies or makes appropriate referrals.
• Communicates and collaborates with patient/significant others/providers/payers to coordinate services that improve access to appropriate services across the continuum of care and which promotes optimal health in a cost-effective manner.
• Measures patient care outcomes, interprets reports and analyzes data trends for groups of patients. Provides direction to specified projects/programs pertaining to the population, assessing, planning, developing/maintaining, implementing and evaluating outcomes of same.
• Documents patient data, plan, interventions and outcomes according to department guidelines.

Qualifications

• Required Bachelor\'s Degree or equivalent nursing or a healthcare related field

• 3 years of relevant experience clinical nursing and or case management/managed care or related field Required

• LIC-Registered Nurse (RN) - STATE_MI State of Michigan Upon Hire required
• CRT-Basic Life Support (BLS) - AHA American Heart Association Ambulatory within 90 days of hire Or
• CRT-Basic Life Support (BLS) - ARC American Red Cross Ambulatory within 90 days of hire

Physical Demands

• Pallet to Waist (6" from floor) > 5 lbs: Seldom up to 20 lbs
• Waist to Waist > 5 lbs: Seldom up to 20 lbs
• Waist to Chest (below shoulder) > 5 lbs: Seldom up to 5 lbs
• Waist to Overhead > 5 lbs: Seldom up to 5 lbs
• Bilateral Carry > 5 lbs: Seldom up to 10 lbs
• Unilateral Carry > 5 lbs: Seldom up to 10 lbs
• Pushing Force > 5 lbs: Seldom up to 25 lbs
• Pulling Force > 5 lbs: Seldom up to 20 lbs
• Sitting: Frequently
• Standing: Frequently
• Walking: Frequently
• Forward Bend - Standing: Seldom
• Forward Bend - Sitting: Seldom
• Trunk Rotation - Standing: Seldom
• Trunk Rotation - Sitting: Seldom
• Squat: Seldom
• Stair Climbing: Seldom
• Reach - Above Shoulder: Seldom
• Reach - at Shoulder or Below: Seldom
• Handling: Seldom
• Forceful Grip > 5 lbs: Seldom
• Forceful Pinch > 2 lbs: Seldom
• Finger/Hand Dexterity: Occasionally

Primary Location SITE - Lakeland Hospital St Joseph - 1234 Napier Ave - St Joseph

Department Name Department of Clinical Transformation - Care - CHS

Employment Type Full time

Shift Day (United States of America)

Weekly Scheduled Hours 40

Hours of Work 8:00 a.m to 5:00 p.m.

Days Worked Monday to Friday

Weekend Frequency N/A

CURRENT COREWELL HEALTH TEAM MEMBERS \xe2\x80\x93 Please apply through Find Jobs from your Workday team member account. This career site is for Non-Corewell Health team members only.

Corewell Health is committed to providing a safe environment for our team members, patients, visitors, and community. We require a drug-free workplace and require team members to comply with the MMR, Varicella, Tdap, and Influenza vaccine requirement if in an on-site or hybrid workplace category. We are committed to supporting prospective team members who require reasonable accommodations to participate in the job application process, to perform the essential functions of a job, or to enjoy equal benefits and privileges of employment due to a disability, pregnancy, or sincerely held religious belief.

Corewell Health grants equal employment opportunity to all qualified persons without regard to race, color, national origin, sex, disability, age, religion, genetic information, marital status, height, weight, gender, pregnancy, sexual orientation, gender identity or expression, veteran status, or any other legally protected category.

An interconnected, collaborative culture where all are encouraged to bring their whole selves to work, is vital to the health of our organization. As a health system, we advocate for equity as we care for our patients, our communities, and each other. From workshops that develop cultural intelligence, to our inclusion resource groups for people to find community and empowerment at work, we are dedicated to ongoing resources that advance our values of diversity, equity, and inclusion in all that we do. We invite those that share in our commitment to join our team.

You may request assistance in completing the application process by calling 616.486.7447.

Corewell Health