RN Care Coordinator Ambulatory Transitions of Care

apartment Corewell Health location_onSouthfield, MI 48033, US

Care Coordinator Ambulatory Transitions of Care

Scope of Work:

Provides care management and care coordination for patients following an acute care hospitalization. Uses evidence-based interventions and defined workflows to support successful transitions of care. Responsibilities include collaboration with members of the health care team to ensure the delivery of quality, efficient, patient center and cost-effective healthcare services.

The role includes a required three to six month orientation period at the Corewell Health Southfield Center, followed by a transition to a work-from-home arrangement with occasional time in the office as required.

Using a variety of methods and tools, identifies targeted high-risk population and chronically ill population within practice sites. Assesses the healthcare, educational, and psychosocial needs of the patient/family. Uses appropriate assessment tools such as depression screening, functionality, and health risk assessment.
Collaborates with Primary Care Physician, 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. 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.
Conducts comprehensive assessments 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.
Using evidence-based guidelines and clinical tools, identifies patients with chronic conditions, and gaps in clinical care. 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 including medication reconciliation, coordinates physician follow-up appointments, symptoms assessment and patient education/ discharge instructions, and problem-solves barriers to compliance.
Maintains required documentation for all care management activities. Works with practice and Physician Organization/Accountable Care Organization leadership to continuously evaluate processes, identify problems, and propose/develop process improvement strategies to enhance the Patient Centered Medical Home delivery model and meet value-based reimbursement payer program requirements.
Reviews the current literature regarding effective engagement and communication strategies, care management strategies, and behavior change strategies and incorporates into clinical practice.
Provides education 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.

Qualifications

Required Associate's Degree or equivalent Graduate of an accredited school of nursing.
Preferred Bachelor's Degree of Science in Nursing.

2 years of relevant experience Minimum two years’ RN experience in a clinical care setting. Required
3 years of relevant experience Three to five years’ experience in care management, home care and/or discharge planning. Preferred
Experience in an ambulatory practice setting. Preferred

Registered Nurse (RN) - STATE_MI State of Michigan Upon Hire required
At least one License and/or Certification in area of specialty - UNKNOWN Unknown Care Management Upon Hire preferred

How Corewell Health cares for you

Comprehensive benefits package to meet your financial, health, and work/life balance goals. Learn more here.
On-demand pay program powered by Payactiv
Discounts directory with deals on the things that matter to you, like restaurants, phone plans, spas, and more!
Optional identity theft protection, home and auto insurance, pet insurance
Traditional and Roth retirement options with service contribution and match savings
Eligibility for benefits is determined by employment type and status

Primary Location

SITE - Corewell Health Southfield Center - 26901 Beaumont Blvd

Department Name

Care Management - Medical Group East WB Mkt

Employment Type

Full time

Shift

Day (United States of America)

Weekly Scheduled Hours

Hours of Work

8:00 a.m. to 5:30 p.m.

Days Worked

Monday to Friday

Weekend Frequency

N/A

CURRENT COREWELL HEALTH TEAM MEMBERS – 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.

Share this job

Related Jobs

PCU

Full-time

RN Intermediate Care

apartment Corewell Health location_onTrenton, MI

About this unit Intermediate Care Unit is a 24-bed unit. All beds are private and have telemetry monitoring. The unit admits patients aged 15 through end of life. IMC sees a wide variety of diagnoses including but not limited to heart failure, respiratory illness, renal failure, and post-heart catheterization patients. ACLS certification is required within 6 months of employment. ACLS certified nurse’s care for overflow medical/surgical/traumatic conditions with low to mild probability for complications/instability and who require non-invasive assessment/interventions every two to eight hours, as well as hospice and end of life care. Corewell Health Trenton Hospital Corewell Health Trenton Hospital is a 193-bed, acute care teaching hospital that sponsors nine university-affiliated residency programs. This Magnet®-designated facility provides comprehensive medical and surgical care for its patients and is one of four recipients of the Truven Health Advantage Award in the category of Health and Clinical Outcomes. Here, you’ll find the only verified Level II trauma center in the region; nationally recognized heart, vascular and pulmonary specialties; a wide array of surgical services, including minimally invasive robotic procedures and orthopedic and neurosurgery services; and comprehensive women’s health services ranging from gynecological to advanced breast care. Scope of Work The clinical nurse, under the ANA scope of practice utilizes the framework of the nursing process to provide professional nursing care by incorporating patient-family centered care principles. The Clinical Nurse provides quality patient care under the direction of the Nurse Leader according to Corewell Health policies and procedures. Qualifications Associates in Nursing Required Bachelors in Nursing Required within 5 years Graduates from a non-accredited school of nursing must have at least one year of acute care experience or at least two years of experience in a licensed health care role and must have successfully passed the NCLEX licensure examination. MI Registered Nurse (RN) Required Basic Life Support (BLS) required upon hire from one of the following organizations - American Heart Association, American Red Cross, or Canadian Heart and Stroke. AHA Advanced Cardiovascular Life Support (ACLS) Required within 6 months Specialty Certification highly recommended within 2 years 1 year of experience as an RN in the IC How Corewell Health cares for you Comprehensive benefits package to meet your financial, health, and work/life balance goals. Learn more here . On-demand pay program powered by Payactiv Discounts directory with deals on the things that matter to you, like restaurants, phone plans, spas, and more! Optional identity theft protection, home and auto insurance, pet insurance Traditional and Roth retirement options with service contribution and match savings Eligibility for benefits is determined by employment type and status Primary Location SITE - Trenton Hospital - 5450 Fort St - Trenton Department Name Progressive Care Unit 3rd Fl - Trenton Hosp Employment Type Full time Shift Night (United States of America) Weekly Scheduled Hours 36 Hours of Work 7pm-7:30am Days Worked varies Weekend Frequency Every other weekend CURRENT COREWELL HEALTH TEAM MEMBERS – 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.

ICU

Full-time

RN SICU

apartment Corewell Health location_onTrenton, MI

About the unit SICU cares for patients 15 and over who are hemodynamically unstable and who require continuous medication infusions, and/or intensive nursing care. SICU is a very faced paced intensive care unit that cares for a large population of Level 1 and Level 2 trauma patients. Other patients commonly cared for in SICU include neurosurgery, neurology, vascular surgery, and other acute surgical patients. The unit serves as the hospital’s stroke designated ICU, and massive transfusion experts. Specialized equipment used in SICU include CRRT, Level 1 transfuser, Camino ICP monitor, and ventriculostomy Accudrain. Nurse to patient ratio is typically 2:1 unless patient acuity calls for 1:1 nursing care. SICU is known for their outstanding teamwork, welcoming environment and multidisciplinary approach to patient care. SICU is proud of the outstanding quality and patient outcomes the team strives to achieve for all patients. About Trenton Hospital This Magnet®-designated facility provides comprehensive medical and surgical care for its patients and is one of four recipients of the Truven Health Advantage Award in the category of Health and Clinical Outcomes. It is home to nine university affiliated residency programs. Here, you will find a Level II trauma center that is a nationally recognized heart, vascular and pulmonary specialties along with other specialties like orthopedics, neurosurgery, and women’s health. Scope of work The RN, under the ANA scope of practice utilizes the framework of the nursing process to provide professional nursing care by incorporating patient-family centered care principles to assess, plan, implement, evaluate, and discharge. The RN provides quality patient care under the direction of the Nurse Leader according to Corewell Health policies and procedures and recognizes the impact of nursing care and patient/family partnerships on patient outcomes. The RN partners with and utilizes patient/family input and goals in planning plan of care and develops teaching strategies for patient/family; documents education and learning appropriately in health record. Qualifications Associates in Nursing Required Bachelors in Nursing Required within 5 years Graduates from a non-accredited school of nursing must have at least one year of acute care experience or at least two years of experience in a licensed health care role and must have successfully passed the NCLEX licensure examination. MI Registered Nurse (RN) Required AHA or ARC Basic Life Support (BLS) Required AHA Advanced Cardiovascular Life Support (ACLS) Required within 6 months Specialty Certification highly recommended within 2 years How Corewell Health cares for you Comprehensive benefits package to meet your financial, health, and work/life balance goals. Learn more here . On-demand pay program powered by Payactiv Discounts directory with deals on the things that matter to you, like restaurants, phone plans, spas, and more! Optional identity theft protection, home and auto insurance, pet insurance Traditional and Roth retirement options with service contribution and match savings Eligibility for benefits is determined by employment type and status Primary Location SITE - Trenton Hospital - 5450 Fort St - Trenton Department Name Intensive Care Unit Surgical 5th Fl - Trenton Hosp Employment Type Full time Shift Day (United States of America) Weekly Scheduled Hours 36 Hours of Work 3:00 a.m. - 3:30 p.m. Days Worked Variable; Self Schedule Weekend Frequency Every other weekend CURRENT COREWELL HEALTH TEAM MEMBERS – 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.

Med-Surg

Part-time

RN Med Surg

apartment Corewell Health location_onTrenton, MI

About the unit 4 Med Surg is comprised of a 38-bed unit with all private rooms. The unit includes 4 bariatric capable rooms, 2 negative pressure rooms and telemetry capability. We take a variety of patients including but not limited to renal issues, abdominal pain, complicated UTIs, post-op patients, CIWA patients, psych patients, SOB/COPD exacerbation, hospice, anemia, pneumonia, DVT, and seizure management. Med/surg is a great way to grow your nursing skills in time management and assessment no matter you years of experience. We are a great team that is very engaged in patient safety and have maintained very high-quality scores. Trenton is a Magnetic Designated hospital with Level Two Trauma, and Stroke Certification. About Trenton Hospital This Magnet®-designated facility provides comprehensive medical and surgical care for its patients and is one of four recipients of the Truven Health Advantage Award in the category of Health and Clinical Outcomes. It is home to nine university affiliated residency programs. Here, you will find a Level II trauma center that is a nationally recognized heart, vascular and pulmonary specialties along with other specialties like orthopedics, neurosurgery, and women’s health. Scope of work The RN, under the ANA scope of practice utilizes the framework of the nursing process to provide professional nursing care by incorporating patient-family centered care principles to assess, plan, implement, evaluate, and discharge. The RN provides quality patient care under the direction of the Nurse Leader according to Corewell Health policies and procedures and recognizes the impact of nursing care and patient/family partnerships on patient outcomes. The RN partners with and utilizes patient/family input and goals in planning plan of care and develops teaching strategies for patient/family; documents education and learning appropriately in health record. Qualifications Associates in Nursing Required Bachelors in Nursing Required within 5 years Graduates from a non-accredited school of nursing must have at least one year of acute care experience or at least two years of experience in a licensed health care role and must have successfully passed the NCLEX licensure examination. MI Registered Nurse (RN) Required AHA or ARC Basic Life Support (BLS) Required upon hire Specialty Certification highly recommended within 2 years How Corewell Health cares for you Comprehensive benefits package to meet your financial, health, and work/life balance goals. Learn more here . On-demand pay program powered by Payactiv Discounts directory with deals on the things that matter to you, like restaurants, phone plans, spas, and more! Optional identity theft protection, home and auto insurance, pet insurance Traditional and Roth retirement options with service contribution and match savings Eligibility for benefits is determined by employment type and status Primary Location SITE - Trenton Hospital - 5450 Fort St - Trenton Department Name Med Surg Care Unit 4th Fl - Trenton Hosp Employment Type Part time Shift Night (United States of America) Weekly Scheduled Hours 24 Hours of Work 7:00pm to 7:30am Days Worked Variable Weekend Frequency Every other weekend CURRENT COREWELL HEALTH TEAM MEMBERS – 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.

Part-time

RN Surgery PRN

apartment Corewell Health location_onTrenton, MI

About Trenton Hospital This Magnet®-designated facility provides comprehensive medical and surgical care for its patients and is one of four recipients of the Truven Health Advantage Award in the category of Health and Clinical Outcomes. It is home to nine university affiliated residency programs. Here, you will find a Level II trauma center that is a nationally recognized heart, vascular and pulmonary specialties along with other specialties like orthopedics, neurosurgery, and women’s health. Scope of work As a Clinical Nurse with Corewell Health, providing top-notch patient care is paramount. You'll be responsible for using the nursing process framework and incorporating patient-family-centered care principles to ensure the highest quality of care. Under the direction of the Nurse Leader, you'll be a vital member of our team, making a real difference in the lives of our patients and their families. Qualifications Associates in Nursing Required Bachelors in Nursing Required within 5 years Graduates from a non-accredited school of nursing must have at least one year of acute care experience or at least two years of experience in a licensed health care role and must have successfully passed the NCLEX licensure examination. MI Registered Nurse (RN) Required AHA or ARC Basic Life Support (BLS) Required within 90 days 2 years of acute care RN experience required 1 year of OR Circulating RN experience preferred How Corewell Health cares for you Comprehensive benefits package to meet your financial, health, and work/life balance goals. Learn more here . On-demand pay program powered by Payactiv Discounts directory with deals on the things that matter to you, like restaurants, phone plans, spas, and more! Optional identity theft protection, home and auto insurance, pet insurance Traditional and Roth retirement options with service contribution and match savings Eligibility for benefits is determined by employment type and status Primary Location SITE - Trenton Hospital - 5450 Fort St - Trenton Department Name Operating Room - Trenton Hosp Employment Type Part time Shift Rotating (United States of America) Weekly Scheduled Hours 0.1 Hours of Work 12 Days Worked Variable Weekend Frequency Variable weekends CURRENT COREWELL HEALTH TEAM MEMBERS – 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.

Full-time

Registered Nurse-Coordinator Patient Care Services - Emergency Department -Oxford

apartment McLaren Health Care location_onOxford, MI

Dept: Emergency Department Hours per pay period: 80 Hours Schedule: Variable Position Summary: Responsible for overseeing patient flow and the nursing plan of care for patients within the Emergency Department (ED) in accordance with established hospital and nursing policies, procedures and standards. Assists with patient care on an as-needed basis. Plans, implements, coordinates, and evaluates ED staffing and patient care. Guides and mentors all ED staff in daily nursing activities and decision making for patient and serves as a resource to the ED staff. Participates in the personal development plan for nursing staff. Oversees departmental nursing quality assessment and continuous quality improvement activities, as directed. Essential Functions and Responsibilities: Ensures clinical quality and efficiency within the Emergency Department. Responsible for assisting with staffing and scheduling of ED personnel. Adjusts and allocates assignments to meet patient demand and assure appropriate break and meal periods for staff. Assists in staff orientation, annual skills review, and mandatory/continuing education programs and other staff development opportunities. Function as a role model and nursing mentor to all ED staff. Participates in the Corrective Action and Annual Performance Evaluation processes of the nursing personnel. Assists with all aspects of patient care on an as-needed basis. Monitor and modify ED patient flow within the department to maximize efficiency, maintain quality, and promote patient satisfaction and employee/physician engagement. Assures the reporting, handling, and documentation of all patient incidents, variances in patient care, issues related to substandard quality of care, and safety issues. Keeps appropriate department leadership informed of all concerns, problems and project progress. Maintains proficiency for all nursing related equipment, supplies, forms and procedures utilized within the ED. Performs other related job duties as requested. Qualifications: Required: Two year ED experience as an RN Associates degree. Graduate of a Nursing program. Current State of Michigan Registered Nurse license BLS certification from American Heart Association (AHA), American Red Cross (ARC), or Canadian equivalent, is required before start date and valid at least 60 days beyond start date . ACLS, TNCC and ENPC required by end of Unit Orientation. Preferred Current ACLS, TNCC and ENPC certification Bachelors degree in Science in Nursing Leadership experience Additional Information Schedule: Full-time Requisition ID: 26000357 Daily Work Times: Variable Hours Per Pay Period: 80 On Call: No Weekends: Yes