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Job Description

Job Summary

Serves as a population health subject mater expert in the practice. Plans and prioritizes care for individuals and population of patients, focusing on strategies that will promote optimal health within populations and directs patients to the right care team member at the right time. Demonstrates expertise, current knowledge in nursing care and management of a sub population of patients of varying complexity and seeks to improve patient, family and health systems / community outcomes through the application of educational concepts / skills and preventive care in a managed care environment.

Essential Functions

• Assesses patients within the practice (inpatient and outpatient) to identify patient/significant others’ needs, level of intensity, insurance benefits and other patient resources while directing the patients to the right level of care within the office.
• Develops plan of care focused on lifestyle management, managing many aspects of high value annual wellness visits, and coordinating shared medical appointments and makes recommendations to PCPs, specialists and other members of the health care team regarding care management strategies, identifying strategies to maximize continuity of care across the continuum.
• Triage and direct patient to the appropriate care team member to meet the patient needs. Assesses the educational needs of patients, families and members of the health care team and develops and implements appropriate teaching strategies or makes appropriate referrals.
• Communicates and collaborates with patient/significant others/providers/payers to coordinate services that improve access to appropriate services across the continuum of care and which promotes optimal health in a cost-effective manner.
• Measures patient care outcomes, interprets reports and analyzes data trends for groups of patients. Provides direction to specified projects/programs pertaining to the population, assessing, planning, developing/maintaining, implementing and evaluating outcomes of same.
• Documents patient data, plan, interventions and outcomes according to department guidelines.
  

Qualifications

• Required Bachelor's Degree or equivalent nursing or a healthcare related field

• 3 years of relevant experience clinical nursing and or case management/managed care or related field Required

• LIC-Registered Nurse (RN) - STATE_MI State of Michigan Upon Hire required
• CRT-Basic Life Support (BLS) - AHA American Heart Association Ambulatory Upon Hire required Or
• CRT-Basic Life Support (BLS) - ARC American Red Cross Ambulatory Upon Hire required

Primary Location

SITE - Zeeland Medical Office Building - 8333 Felch - Zeeland

Department Name

Family Medicine - Zeeland

Employment Type

Full time

Shift

Day (United States of America)

Weekly Scheduled Hours

38

Hours of Work

7:00 a.m. to 5:00 p.m.

Days Worked

Monday to Friday

Weekend Frequency

N/A

Spectrum Health requires all team members to receive the COVID-19 vaccinations subject to certain exclusions based on the team member’s job category. Spectrum Health is committed to granting reasonable accommodations in accordance with applicable laws.

Accommodation Notice: If you are a qualified individual with a disability, you may request a reasonable accommodation in Spectrum Health's application process. Contact us at 616-486-SHHR (7447).

Spectrum 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, sexual orientation, veteran status, or any other legally protected

category. See more here.