RN Care Manager

Welcome to Cherry Health - video about Cherry Health This is a full time, benefit eligible position typically working Monday - Friday 8am-5pm onsite at our Westside Health Center. This role will travel to other Cherry Health medical sites around West Michigan. The RN Care Manager is responsible for conducting Medicare Annual Wellness Visits (AWV) across multiple Cherry Health medical sites. T he Care Manager will work collaboratively with the primary care provider and the Medicare beneficiary to conduct a health risk assessment and preventative services plan to promote health and wellness for the year ahead.

As part of an expanded healthcare role, the Care Manager collaborates with specialists, members of the healthcare team, and patients/families to ensure the delivery of quality, efficient, and cost-effective healthcare services. This position will assist providers in achieving desired patient outcomes by working collaboratively with providers, the multidisciplinary team, and the community medical neighborhood. The position requires adherence to organizational Policies, Procedures, Code of Ethics, and all licensing and accreditation standards. The RN must also represent the organization’s mission in all actions and communications.

Essential Duties and Responsibilities: Identify and outreach to patients due for Medicare AWVs utilizing targeted patient lists. Assess over time the healthcare, educational, and psychosocial needs of the patient/family using standardized assessment tools such as depression screening, functionality, and health risk assessments. Collaborate with primary care providers, patients, and members of the healthcare team, including continuum of care settings and the community, to develop a comprehensive individualized care plan and targeted interventions. Provide patient self-management support, focusing on empowering the patient/family to build capacity for self-care.

Act as the lead in ensuring continuity of care that extends beyond the practice boundaries. Serve as a liaison to acute care hospitals, specialists, and post-acute care services. Provide follow-up and coordination with patients/families experiencing a discharge or transition from an inpatient acute care setting. Complete and maintain required documentation of timely post-hospital visit follow-up, medication reconciliation, primary care provider or specialist follow-up appointments, teaching warning signs, reviewing discharge instructions, coordinating care, and problem-solving barriers.

Collaborate with Cherry Health’s leadership to continuously evaluate processes, identify problems, and propose/develop process improvement strategies to enhance care management and Patient-Centered Medical Home delivery of care models. Understand and adhere to Cherry Health’s compliance standards as they appear in Cherry Health’s Corporate Compliance Policy, Code of Conduct, and Conflict of Interest Policy. Keep abreast of all pertinent federal, state, and Cherry Health…

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