Grace Health is seeking a confident nurse to collaborate with inner departments and functions to best meet patient's needs.

EXAMPLES OF DUTIES: (This list is not all inclusive.)

1. Assessment of patient/family’s health, pain, nutritional, psychosocial, behavioral, cultural, age specific and learning needs.

2. Applies the principles of the nursing process to improve care outcomes for complex, high-risk patients with chronic medical and psychological/behavioral diseases, through collaboration with care team providers, support staff, and behavioral health department.

3. Conducts transitional care coordination for patients newly discharged from an in-patient setting to reduce hospital re-admission rates for Grace Health patients.

4. Uses principles of learning to perform education with the patient and family

5. Assess medical necessity, utilization / care management progress.

6. Identify services and care needed and recommends resources if appropriate by analyzing clinical protocols. Assess patient’s health, pain, nutritional, psychosocial, behavioral, cultural, age-specific, and learning needs.

7. Develops and implements plans to increase patient motivation, self-management, and self-efficacy in all aspects of chronic disease management and prevention.

8. Monitors quality measures related to individual and targeted sub-populations to reduce gaps in evidence-based care.

9. Reviews care with DME providers and assists patients with closing gaps in care, using your ability to critically think through multidisciplinary care.

10. Assess and evaluate patient’s needs and requirements to achieve and/or maintain their health

11. Provide resources to optimize health and well-being. These may include education and/or coordination of community-based support services.

12. Ability to work as a team and communicate information to the team/neighborhood in order to coordinate patient care.

13. Communicates with patients/family about the plan of care.

14. Identifies patients being discharged from area hospitals.

15. Contacts patients within two business days of being discharged from the hospital.

16. Assesses patients for readmission risk using standardized tool.

17. Maintains required licensure and optional certification.

18. Although each position has its own unique duties and responsibilities, please refer to the policy on Job Descriptions for details that apply to every position.


Knowledge, Skills and Abilities:

  • Knowledge of professional nursing theory.
  • Knowledge of organizational policies and procedures.
  • Knowledge of medical equipment.
  • Skill in the technical aspects of care.
  • Skill in the use of technology related to patient care and the documentation of patient care (EMR / EHR).
  • Skill in the use of Microsoft Outlook, Word, and Excel.
  • Ability to accurately assess the needs of the patient/family in person and over the phone.
  • Ability to communicate effectively with the patient, family and coworkers.
  • Ability to prioritize.
  • Ability to problem solve.
  • Ability to interpret information from multiple sources.

Education: Graduate of an accredited school of nursing

Experience: One year of professional nursing experience in ambulatory care preferred

Certificate/License: Current Registered Nurse license in the state of Michigan, Certification in ambulatory care nursing or other nursing specialty is desirable, Current BCLS certification