The Care Management Nurse will work together with other members of the Care Team to provide high quality, well-coordinated, highly organized, patient-centered care to patients and their families/care givers/support systems. The CM primary focus will be the ongoing and/or intermittent management of patients identified as high risk via a comprehensive risk stratification process or otherwise identified by providers as needing care management. The CM acts in the capacity of a clinical support role to the Provider led Care Team and is an integrated, essential member of the care team for high-risk patients. The RN Care Manager supports GLBHC sites in providing a team-based approach to care. Participates in activities related to Quality Improvement.

ESSENTIAL JOB DUTIES

Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Primary Accountabilities

At Great Lakes Bay Health Centers the primary accountability of the Care Management Nurse role will be to facilitate and guide patients through ongoing clinical and self-management support resulting in improved access, improves clinical outcomes or decreased cost of care as a key aspect of Patient Centered Care through outreach, enrollment, engagement, education, individualized care planning and self-management support strategies. The Care Management Nurse will focus on improving functional health status and decreasing disease burden while educating and empowering patients to actively participate in their care. The Care Management Nurse will identify patients with a high-risk score as defined in the population health management system and engage patients in the Care Management program. As a driver of the Population Health strategy, the Care Management Nurse will gather data on the populations of focus, stratify relevant metrics/risk factors, and engage patients in comprehensive Care Management engaging other care team members such as the: Staff Nurse, Community Health Worker, Integrated Behavioral Health, and others as necessary. The Care Management Nurse will partner with and guide the care teams to ensure safe, timely, efficient, and effective transitions of care for patients -- both within and outside of the primary care practice. The role of the Care Management nurse is focused around 7 main accountabilities.

1. Identifying Population of Focus through risk stratification or provider referral. Risk scores include, at a minimum a collection of data on the following characteristics:

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``` 1. 1. Diseases diagnosis 2. Social Determinants of Health 3. ER and Hospital Admissions 4. Behavioral Health conditions and indicators

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``` 1. Understanding of contributing factors to risk score and developing a relevant and appropriate care plan. 2. Patient Outreach & Enrollment in Care Management Program. 3. Collaborate to Develop Individualized Care Plan. 4. Review and Update Care Plan routinely. 5. Provide Clinical support and Care Management, Education, Self-Management Support and ongoing communication with patients on a CM panel/registry. 6. Integration and facilitation of relevant and comprehensive care team.

Operational Excellence

1. Uses professional skills to the best of their ability.
2. Provides a positive patient-centered experience for every patient.
3. Considers safety of patients and works to help provide a safe environment.
4. Maintains a current up-to-date knowledge of new policies and procedures.
5. Follows and optimizes concepts of Patient Centered Care Delivery
6. Follow the minimum set protocols for patient engagement, documentation, and care management interventions.

Relationship Management

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