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The role targets adult patients with chronic conditions at risk for progression, complications, and functional decline through individualized care planning, proactive outreach, assessments, education, and care transition coordination. 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It develops and implements individualized care plans to improve clinical outcomes and quality of life.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"What qualifications and performance skills are required?",{"text":113,"@type":109},"The role requires graduation from an accredited nursing school and a valid unrestricted Michigan RN license, plus a driver’s license and ability to drive to multiple locations. 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In collaboration with the physician and interdisciplinary team, the RN Care Manager develops and implements an individualized care plan designed to promote the patient , family/caregiver’s understanding, and management of their condition, optimize quality of life, and improve clinical outcomes. This position provides service in the primary care practices, telephonic outreach, telemedicine, and individual patient homes.  \nResponsibilities & duties  \n• Actively seeks to engage moderate and high-risk patients in the care management program through proactive telephonic outreach, telemedicine, practice, and homebased encounters.  \n• Conduct comprehensive assessments (in-home, in primary care practice, telemedicine or telephonic encounter) to identify the patient’s needs and goals, health behaviors, functional and/or cognitive impairment, psychosocial issues, environment, and areas of risk that may impact the patient’s adherence to the treatment plan.  \n• In collaboration with the interdisciplinary care team, develop an individualized care plan and intervention strategies to meet the patients’ needs and focused on improved clinical outcomes and patient satisfaction. The RN Care Manager will monitor the care plan for effectiveness, review with the primary care physician, and modify as needed to optimize the patient’s progress and well-being.  \n• Establish and support the patient’s self-management goals.  \n• Provides education on management of chronic conditions and enhances the patient’s self-efficacy to prevent progression or exacerbation of chronic illness and promote healthy behavior change.  \n• Coordinate care transitions and monitoring of high-risk patients following hospital and sub-acute discharges to ensure timely follow-up with primary care and prevent readmissions.  \n• Facilitate discussions with the patient and caregiver regarding advance directives and palliative care.  \n• Align resources with the patient including referrals to other disciplines of the care management team, home care, community resources, and other healthcare providers.  \n• Actively participate in Care Management Department monthly meetings and multidisciplinary care team conferences, huddles, and discipline specific team meetings.  \n• Maintain timely and complete medical record documentation and billing of all care management encounters.  \n• Work with the practice and physician organization to continuously evaluate processes and develop improvements to advance the care management program.  \n• Serve as a positive ambassador for United Physicians in the practices, and support initiatives leading to practice transformation.  \n• Adhere to the scope of practice for Registered Nurses per state regulatory guidelines.  \n• Respect confidentiality of all persons and follow state, federal and organization policies, and procedures.  \n• Effectively participate in various internal committees and performs other duties as requested by management.  \n• Evaluate patients for needed services (HEDIS metrics) assist in closing “gaps” for needed health services (preventative and condition specific)  \n• Miscellaneous duties and projects as assigned.  \n• Maintain continuing education requirements for Complex Care Management as required for role.  \n• Maintain Healthcare Basic Life Support as required for role.  \n\n| Qualifications\u003Cbr>• Graduate of accredited school of nursing, BSN\u003Cbr>• Valid unrestricted State of MI Nursing License required.\u003Cbr>• Valid unrestricted State of MI Driver’s License and ability to drive to multiple locations.\u003Cbr>• Cert","cbCaikZmjAikqeFM","https://ap.wps.com/l/cbCaikZmjAikqeFM","pdf",149622,"English","# Registered Nurse Care Manager Job Description\n## Purpose of the Position\n## Responsibilities & Duties\n## Qualifications\n## Performance Skills\n## Disclaimer","[{\"question\":\"What is the purpose of the Adult RN Care Manager position?\",\"answer\":\"The Adult RN Care Manager supports the primary care physician network by serving patients with chronic conditions at risk for disease progression, complications, and decline. It develops and implements individualized care plans to improve clinical outcomes and quality of life.\"},{\"question\":\"What qualifications and performance skills are required?\",\"answer\":\"The role requires graduation from an accredited nursing school and a valid unrestricted Michigan RN license, plus a driver’s license and ability to drive to multiple locations. Performance skills include advanced interviewing and assessment, strong communication and problem-solving abilities, knowledge of case management guidelines, and proficiency with computer applications and electronic medical records.\"},{\"question\":\"What compliance and administrative duties must be followed?\",\"answer\":\"The position requires adherence to the RN scope of practice, confidentiality, internal policies and procedures, timely and complete medical record documentation and billing, and participation in committees and meetings. It also includes continuing education and required basic life support for the role.\"}]","Adult RN Care Manager Job Description - Responsibilities and Qualifications | PDF",1789339890]