Title: Care Manager and Triage Nurse
City, State: Alma, Michigan
Location: Sacred Heart Mercy Health Care Clinic
Additional Job Details: FT Days, 40 Hours, Weekly

SUMMARY
Sacred Heart Mercy Health Care Center is a Clinic dedicated to provide comprehensive medical care to those most in need in our area. The Clinic is an apostolate of the Religious Sisters of Mercy of Alma, MI, with the care provided flowing from the charism of Mercy.

The Care Manager and Triage Nurse works with patients both in-person and over the phone to ensure continuity of care following discharge from the hospital, comprehensive management of complex diseases and support for patients with barriers to care. Phone call triage gives patients the opportunity to present acute concerns and have most appropriate follow up. This position is essential to the comprehensive care provided by the Clinic and to help eliminate barriers to care.

ESSENTIAL FUNCTIONS:
Care Management:
1. Identifies high-risk patients via referral from PCP or Specialist, risk stratification, and patient lists from Quality Coordinator, to determine which patients are most appropriate for care management.

2. Calls patients after hospitalizations in a timely manner (within 2 business days of discharge), to ensure seamless transitions of care and ensure patient has access to appropriate resources. Performs medication reconciliation during phone call.

3. Meets with patients via phone, video or in-person visits for care management visits to provide education, tools for management of chronic conditions, and resources.

4. Utilizes validated tools to assess patient understanding of medical conditions, social needs, and other barriers to care. Works with patient to set self-management goals based on needs assessment and re-evaluates periodically to determine if patient is meeting goals.

5. Collaborates with PCP, patient, family, and other members of the healthcare team as needed to ensure continuity of care.

6. Documents all care management visits appropriately in the EMR system and communicates plan to PCP.

Triage:
1. Addresses patient calls related to health care questions or concerns. Triages calls to Providers as appropriate.

2. Assists with follow-up calls after Emergency Room visits to determine appropriate follow-up.

3. Assists with coordinating access to specialist care by following through on referrals place by Providers, as needed.

4. Assists with other nursing tasks as needed including lab draws, EKGs, and assistance with other procedures.

5. Other tasks as assigned by the Medical Administrator.

REQUIRED EDUCATION AND EXPERIENCE:
1. Graduation from accredited Nursing program.

2. Preferred at least two years of clinical nursing experience.

REQUIRED KNOWLEDGE, SKILLS, and ABILITIES:
1. Alignment with Clinic mission

2. Excellent communication skills.

3. Excellent nursing skills including patient education and clinical assessment.

4. Works effectively with a team for common goals of care.

5. Knowledge of current management guidelines for chronic diseases.

PHYSICAL DEMANDS:
1. Mobility and ability to sit, bend, reach and lift 25 lbs.

2. Sufficient near vision acuity to read information appearing on computer display screen, in hand-written forms, and printed on paper

3. Adequate hearing and verbal abilities to communicate effectively in person and by telephone

How To Apply
Contact Sister Mary Lisa Renfer, RSM, DO at 989-463-3451, ext. 210 or by e-mail at krenfer@sacredheartmercy.org.

Sacred Heart Mercy Health Care Clinic

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Care Manager and Triage Nurse