Outpatient Based Care Manager - Primary Care Livonia

Trinity Health Corporation Livonia, MI

16301_45060 SJMG Primary Care Livonia - SM

Expected Weekly Hours:



Position Purpose:

Job Description Details:

An Opportunity to Join our Remarkable Care Team in the St. Joe's Medical Group awaits YOU!!!!

St. Joseph Mercy Health System (SJMHS) is one of the nation's top healthcare service providers, spanning five counties in Southeastern Michigan. SJMHS represents more than 2,700 physicians and 14,000 nurses and staff, and includes 5 Hospitals, 5 Outpatient Health Centers, 8 Urgent Care Facilities and over 25 Specialty Centers. Saint Joseph Mercy Health System is part of Trinity Health, one of the largest multi-institutional Catholic health care delivery systems in the nation, serving communities in 21 states with 86 hospitals, 128 continuing care facilities and home health and hospice programs.

St. Mary Mercy Hospital is a beautiful full-service, 304-bed acute care hospital, located in Livonia, MI, that provides comprehensive care, including a 24-hour emergency department, general medicine, inpatient and outpatient surgery, physical medicine and rehabilitation, intensive care unit, cancer, cardiology, geriatrics and birthing and women's health. Through several major expansions in the hospital, programs and services, St. Mary Mercy continues to offer the latest in quality health and medical services. St. Mary Mercy has received numerous awards recognizing excellence in clinical outcomes, patient safety, financial performance and efficiency.

Job Description:

This position requires an RN licensure. Integrated within the Physician Practice setting, the Care Manager is involved in coordinating patient care activities and sharing information among all of the participants concerned with a patient's care to achieve safer and more effective care, in the right place, at the right time. Job duties are focused on fulfilling preventive care needs, managing patients with chronic conditions, and flagging at-risk patients in need of attention.


* Maintain an active caseload of "at risk" patients using identification and stratification tools, direct referrals from the patient's healthcare team and other clinical knowledge.

* Through evaluation, collaboration and recommendation ensure that patients receive the right care, in the right place, at the right time.

* Work collaboratively with physicians and the care team to ensure patient adherence to the medical plan of care and/or evidence-based guidelines, including all appropriate preventive and disease-specific screenings, interventions, and treatment goals; including self-management goals, and contact schedules.

* Work with "at-risk" patients and families on self-management support including:

* Setting short and long-term goals on self-management of chronic disease

* Addressing medication adherence in patients not meeting outcome goals

* Creating a plan for health behavior change by

* Assessing and working on the patient's readiness to change, the importance of change, and confidence in ability to change.

* Helping the patient to identify and overcome barriers.

* Optimizing patient and family independence through teaching and the provision of available and necessary resources to access the health care delivery system across the continuum of care.

* Performing individual needs assessment, care plan design, documentation and implementation, and evaluation of outcomes

* Communicating a plan for healthcare needs between physician/office visits.

* Providing needed patient education regarding specific health care skills and general disease concepts by supplying information materials, directing the patient to available community resources or approved websites.

* Communicating with patients face-to-face, by telephone, or by email.

* Working toward reduction of preventable hospital admissions, re-admissions, excessive therapies, DME, unnecessary use of SNF days, etc.

* Track performance of clinical outcomes for population; document as necessary.

* Utilize EMR/chronic disease registry or other clinical/administrative reporting system to prioritize patient outreach and follow up.

* Ensure care for high risk population is provided across the continuum of the healthcare experience, such as care transition, coordination of community and social services and other providers as needed. Obtain records as needed for care coordination efforts. Monitor that appropriate home care, hospice care, and other ancillary services (DME, infusion services, etc) are in place and are being delivered as directed by the care team. Facilitate the information flow between hospital, long-term care, specialists and home health representatives, and the care team. Provide and facilitate open communication with physicians, office staff as appropriate.

* Utilize provided guidelines to determine if guideline criteria have/have not been met relative to HEDIS, PQRS and/or other quality of care standards as well as administrative or efficiency measures.

* Support Practice with Patient-Centered Medical Home recognition requirements.

* Participate in the development, implementation, and outcomes assessments of quality improvement projects.

* Adapt to change or unusual circumstances in a way that promotes cooperation and minimal disruption to work environment

* Collaborate, communicate and network with other members of the medical neighborhood.



* BSN required or willing to complete per BSN agreement.

* CCM preferred.

* Basic Life Support (BLS) for the Healthcare Provider certified.


Current RN License in the State of Michigan

Training and Experience

* Minimum of 2 years practicing nursing

* Experience in home health or hospital case management

* 5 years of clinical and case management/health coach experience preferred

Job Knowledge

* Sound clinical expertise and knowledge of chronic illness/complex care/pharmacology/pathophysiology.

* Customer-focused interpersonal skills in order to interact in an effective manner with physicians, health team members, community agencies, and patients and families

* Leadership qualities including time management, verbal and written communication skills, listening skills, problem solving, work delegation and work organization

* Knowledge of information technology to evaluate care effectiveness (care processes, outcomes and cost) for individual users of health care and patient populations

* Ability to work autonomously within matrix environment without direct supervision or support

* Demonstrates a wide theory base and sound clinical skills to function as a nurse generalist

* Demonstrates keen assessment skills

Why St. Joseph Mercy Health System?

* Competitive Salaries and Shift Differentials

* Rich Benefits package which include Medical, Dental, Vision, Paid Time off, Retirement Saving Plan with employer contribution option, Tuition Reimbursement, Life Insurance and Short/Long Term Disability.

* Opportunity for growth and advancement throughout Trinity Health in 21 different states!!

Trinity Health's Commitment to Diversity and Inclusion

Trinity Health employs more than 120,000 colleagues at dozens of hospitals and hundreds of health centers in 21 states. Because we serve diverse populations, our colleagues are trained to recognize the cultural beliefs, values, traditions, language preferences, and health practices of the communities that we serve and to apply that knowledge to produce positive health outcomes. We also recognize that each of us has a different way of thinking and perceiving our world and that these differences often lead to innovative solutions.

Trinity Health's dedication to diversity includes a unified workforce (through training and education, recruitment, retention and development), commitment and accountability, communication, community partnerships, and supplier diversity.