Remote work opportunities
As the largest not-for-profit health care system serving Michigan, we offer a world of opportunity within our expansive system. We have more nationally ranked hospitals than any other health system in the state, including six that are Magnet -recognized. In total, Beaumont has eight hospitals and 155 outpatient sites that provide diverse practice settings located in communities throughout southeastern Michigan and the greater Detroit metropolitan area.
Supports care management and care coordination for patients with complex conditions and those with mild to moderate chronic illness. With direction and input from the Ambulatory RN Care Coordinator (CC), supports care management and population management initiatives with the team through process improvement and patient care coordination. Responsibilities include collaboration with patients and the care team to ensure coordination of patients clinical and social care needs.
1. Coordinates care with a targeted high-risk population and chronically ill population within practice sites through patient interaction both telephonically and via face to face encounters. Implements and supports the healthcare, educational, and psychosocial plan of the patient/family created by the care team.
2. Collaborates with Primary Care Physician, Ambulatory RN CC, patient, and members of the health care team, to assess, develop and implement an agreed upon plan of care. Participates in continuous quality improvement to enhance care management in the office setting. Monitors patient/family response to plan of care and revises the care plan as indicated under the direction of the care team. Provides self-management support with a focus on empowering the patient/family to build capacity for self- care. Ensure support for advanced directives and advanced care planning.
3. Collects patient reported information and reports to the RN CC in order complete a comprehensive assessment to identify the member's needs, self-management goals, functional and/or cognitive impairment, psychosocial issues, environment, and areas of risk or barriers that may impact the patient's adherence to the care management plan.
4. Implements systems to ensure necessary care is completed and monitors individual patient progress and population health. Coordinates patient care by linking patients to resources. Provides follow up with patient/family when patient transitions from one setting to another. Completes post hospital discharge calls appropriate to skill set, including medication reconciliation, coordinates physician follow-up appointments, symptoms assessment and patient education/ discharge instructions, and problem-solves barriers to compliance.
5. Maintains required documentation for all care management activities. Works with practice and care team to continuously evaluate processes, identify problems, and propose/develop process improvement strategies to enhance the Patient Centered Medical Home delivery model and value-based payer program requirements.
6. Reviews the current literature regarding effective engagement and communication strategies, care management strategies, and behavior change strategies and incorporates into clinical practice.
7. Provides education allowed under their defined scope of practice on management of chronic conditions and enhances the member's self-efficacy to prevent progression or exacerbation of chronic illness and promote healthy behavior change. Coordinate care transitions and monitoring of high-risk members following hospital and sub-acute discharges to ensure timely follow-up with primary care and prevent readmissions.
This document represents the major duties, responsibilities, and authorities of this job, and is not intended to be a complete list of all tasks and functions. It should be understood, therefore, that incumbents may be asked to perform job-related duties beyond those explicitly described.
1. Supports the Mission, Value and Vision of Beaumont Health (BH). Demonstrates personal commitment through active involvement in the performance improvement process.
2. Exhibits excellent customer service skills and behaviors toward internal and external customers and co-workers. Promotes positive public relations with patients/residents, family members, guests, and others.
3. Supports and adheres to all Beaumont Health's customer service, service excellence, and performance standards. Supports and participates with all required compliance standards that may be department specific and/or identified by the organizations including in-service training, acceptable attendance, uniform and dress code.
4. Adheres to HIPAA requirements and maintains confidentiality of all data, including patient/resident, employee and operations information.
5. Supports and participates in a collaborative team-oriented environment - cooperates and works together with all co-workers, plans and completes job duties, uses appropriate communications in sensitive and emotional situations and follows up as appropriate regarding reported complaints, problems and concerns.
6. Supports, cooperates with and demonstrates safe work practices and attitudes, follows safety rules - including universal precautions - reports and prevents/corrects unsafe conditions and behaviors, and participates in organizational and departmental safety programs.
7. Completes all required compliance standards that may be department specific and/or identified by the organization.
8. Maintains current licensure, registration and/or certification, as applicable, at all times.
To 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 duties.
A. Education / Training:
Graduate of an accredited school or program for Licensed Practical Nursing or other clinically related area with a technical or college-level degree.
B. Work Experience:
Minimum two years' experience in the clinical care setting. One to two years' experience in physician practice setting preferred. Care management, home care and/or discharge planning experience preferred.
C. Certification, Licensure, Registration:
If licensed, requires a current, unrestricted license to practice as required in the State of Michigan.
If certified, requires a current, valid certification in related specialty.
D. Other Qualifications:
Excellent interpersonal and communication skills. Ability to act in an autonomous, self-directed manner in a fast-paced, ever-changing environment.
Knowledge of chronic disease implications, evidence-based guidelines, prevention, wellness, health risk assessment, and patient education.
Excellent judgement, data collection, problem solving, and triage skills
Proficient in computer skills and applications including Excel workbooks
Ability to affect change, work as a productive and effective team member, to be flexible, and adapt to needs/priorities
Demonstrates customer focused interpersonal skills to interact in an effective manner with practitioners, the interdisciplinary health care team, community agencies, patients, and families with diverse opinions, values, and religious and cultural ideals.
Beaumont offers a comprehensive benefits package to meet your financial, health and life-work balance goals.
NEW On-demand pay program - powered by Payactiv
Generous paid time off, holidays and flexible scheduling
Our employees receive special discounts on a wide range of products and services
Exceptional health, dental, vision and prescription drug insurance plans
Generous retirement savings, disability insurance, identify theft protection and even home and auto insurance
A. Physical Effort:
Position requires incumbent to occasionally perform physical activities necessitating ability to push/pull objects up to 20 pounds. Mobility skills such as walking and standing along with performing manual dexterity and coordination functions required.
B. Work Environment:
Incumbent may be occasionally exposed to blood, body fluids, and hazardous substances.
Our diverse and talented teams of professionals and clinicians don't just share in the success of our system; they make it possible. Driven by our shared commitment to making our communities healthier and stronger, we are leading the way in health care innovation with relentless ambition and a belief that anything is possible when we work together.
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Beaumont 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.