The grants RN care manager works with the other members of the grants healthcare team to implement a tailored program for each patient based on the patient's specific clinical risk factors, and patient preferences. The grants RN care manager is responsible for conducting a comprehensive risk assessment; developing and implementing protocol-guided, tailored research care plans for each patient based on needs assessments, patient and caregiver priorities, and primary care physician (PCP) advice. The grants RN care manager is responsible for ongoing communication with involved providers regarding care plans and changes in condition to ensure continuity of care. Grants RN care manager will also be responsible for identifying and coordinating referrals to resources within the healthcare system, home health services, community-based, prevention and other relevant programs.
Essential Functions
Our Trinity Health Culture: Knows, understands, incorporates & demonstrates our Trinity Health Mission, Values, Vision, Actions & Promise in behaviors, practices & decisions.
• Conducting structured assessments of patients in the study and developing and implementing individualized care plans using study protocols.
• Engaging patients and caregivers in self-management using motivational interviewing.
• Communicating care plans and any changes in condition to primary care physician and health care team.
• Conducting in-person clinical visits at which patient and family members' priorities are discussed and their questions about problems, resources, and implementing care plans are answered.
• Providing telephone follow-up to monitor implementation of care plans and support patient self-management; Facilitating appointments with provider; referring, when appropriate, to home-health agencies and local community-based organizations for services and materials and maintaining close working relationships with these organizations.
• Periodically reassessing clinical risk factors and revising care plans accordingly.
• Maintaining clinical information using care management software system
• Participating in quality improvement efforts for the PHSO grants program.
• Assist with grants committee planning and support.
• Document and report program goals and deliverables as required.
Our Commitment
Rooted in our Mission and Core Values, we honor the dignity of every person and recognize the unique perspectives, experiences, and talents each colleague brings. By finding common ground and embracing our differences, we grow stronger together and deliver more compassionate, person-centered care. We are an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or any other status protected by federal, state, or local law.