Job Information
Corewell Health RN Ambulatory Care Coordinator in Southfield, Michigan
This position is Hybrid- onsite required for in person meetings.
About Corewell Health
Our new name signals our bold commitment to health and wellness. At our core, we are here to help people be well so they can live their healthiest life possible. Through health care and health coverage, we create more value. Through compassion, collaboration, clarity, curiosity and courage, we make anything and everything possible. Through our people, we care for the whole person with respect, dignity and love. Everyone deserves opportunities and resources for better health. Everyone deserves our relentless pursuit to innovate and always do better. Everyone deserves to have a community be a great place to live, work, learn and play. We believe health and well-being should be within reach for all. We believe the system to support the entire health and wellness journey starts with prevention. We believe that together we will make a difference. Together, we are here to make health better for everyone. Together, we are Corewell Health.
Scope of Work
Provides care management and care coordination for patients with complex conditions and those with mild to moderate chronic illness. In partnership with the primary care practice leadership team, the Ambulatory RN Care Coordinator leads care management and population management functions within the team through process improvement workflow redesign, providing assistance with training, and delegating to other members of the team. Responsibilities include collaboration with members of the health care team to ensure the delivery of quality, efficient, patient centered, and cost-effective healthcare services.
Using a variety of methods and tools, identifies targeted high-risk population and chronically ill population within practice sites. Assesses the healthcare, educational, and psychosocial needs of the patient/family. Uses appropriate assessment tools such as depression screening, functionality, and health risk assessment.
Collaborates with Primary Care Physician, patient, and members of the health care team, to assess, develop and implement an agreed upon plan of care. Participates in continuous quality improvement to enhance care management in the office setting. Monitors patient/family response to plan of care and revises the care plan as indicated. Provides self-management support with a focus on empowering the patient/family to build capacity for self- care. Ensure support for advanced directives and advanced care planning.
Conducts comprehensive assessments to identify the member’s needs, self-management goals, functional and/or cognitive impairment, psychosocial issues, environment, and areas of risk or barriers that may impact the patient’s adherence to the care management plan.
Using evidence-based guidelines and clinical tools, identifies patients with chronic conditions, and gaps in clinical care. Implements systems to ensure necessary care is completed and monitors individual patient progress and population health.
Coordinates patient care by linking patients to resources. Provides follow up with patient/family when patient transitions from one setting to another. Completes post hospital discharge calls including medication reconciliation, coordinates physician follow-up appointments, symptoms assessment and patient education/ discharge instructions, and problem-solves barriers to compliance.
Maintains required documentation for all care management activities. Works with practice and Physician Organization/Accountable Care Organization leadership to continuously evaluate processes, identify problems, and propose/develop process improvement strategies to enhance the Patient Centered Medical Home delivery model and meet value-based reimbursement payer program requirements.
How we will care for you, while you care for our patients
Comprehensive benefits package to meet your financial, health, and work/life balance goals. Learn more here (https://careers.corewellhealth.org/us/en/benefits-new) .
On-demand pay program powered by Payactiv
Discounts directory with deals on the things that matter to you, like restaurants, phone plans, spas, and more!
Optional identity theft protection, home and auto insurance, pet insurance
Traditional and Roth retirement options with service contribution and match savings
Qualifications
Required Associate's Degree or equivalent Graduate of an accredited school of nursing.
Required Bachelor's Degree of Science in Nursing.
2 years of relevant experience Minimum two years’ RN experience in a clinical care setting. Required
3 years of relevant experience Three to five years’ experience in care management, home care and/or discharge planning. Preferred
Experience in an ambulatory practice setting. Preferred
Registered Nurse (RN) - State of Michigan Upon Hire required
At least one License and/or Certification in area of specialty - Care Management Upon Hire preferred
Primary Location
SITE - Beaumont Service Center - 26901 Beaumont Blvd
Department Name
Quality Management & Patient Safety - CHMG East
Employment Type
Full time
Shift
Day (United States of America)
Weekly Scheduled Hours
40
Hours of Work
8:00 a.m. to 5:00 p.m.
Days Worked
Monday to Friday
Weekend Frequency
N/A
CURRENT COREWELL HEALTH TEAM MEMBERS – Please apply through Find Jobs from your Workday team member account. This career site is for Non-Corewell Health team members only.
Corewell Health is committed to providing a safe environment for our team members, patients, visitors, and community. We require a drug-free workplace and require team members to comply with the MMR, Varicella, Tdap, and Influenza vaccine requirement if in an on-site or hybrid workplace category. We are committed to supporting prospective team members who require reasonable accommodations to participate in the job application process, to perform the essential functions of a job, or to enjoy equal benefits and privileges of employment due to a disability, pregnancy, or sincerely held religious belief.
Corewell 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, gender, pregnancy, sexual orientation, gender identity or expression, veteran status, or any other legally protected category.
An interconnected, collaborative culture where all are encouraged to bring their whole selves to work, is vital to the health of our organization. As a health system, we advocate for equity as we care for our patients, our communities, and each other. From workshops that develop cultural intelligence, to our inclusion resource groups for people to find community and empowerment at work, we are dedicated to ongoing resources that advance our values of diversity, equity, and inclusion in all that we do. We invite those that share in our commitment to join our team.
You may request assistance in completing the application process by calling 616.486.7447.
People are at the heart of everything we do, and the inspiration for our legacy of outstanding outcomes, innovation, strong community partnerships, philanthropy and transparency. Corewell Health is a not-for-profit health system that provides health care and coverage with an exceptional team of 60,000+ dedicated people—including more than 11,500 physicians and advanced practice providers and more than 15,000 nurses providing care and services in 22 hospitals, 300+ outpatient locations and several post-acute facilities—and Priority Health, a provider-sponsored health plan serving more than 1.2 million members. Through experience and collaboration, we are reimagining a better, more equitable model of health and wellness.
