RN Complex Care Manager

Family Health Care; Michigan; Hybrid; USD 70,000 - 90,000; Full time

Job summary

Family Health Care is seeking an RN Complex Care Manager to lead a multidisciplinary care team and assure quality, cost-effective care for high-risk patients. You will coordinate treatment plans, collaborate with PCPs, and guide care within the NextGen EHR Care Management template.

The role emphasizes reducing hospitalizations, providing self-management support, and overseeing infection prevention and control programs across patient populations from neonate to geriatric.

Qualifications

• Current RN Licensure in Michigan
• Associates Degree in Nursing
• Bachelor Degree in Nursing (BSN) preferred
• Minimum 5 years clinical nursing experience
• Knowledge of provider community and community resources in the White Cloud area
• Comprehensive knowledge of insurance company principles and outpatient delivery systems
• APIC Certification is preferred or required as referenced

Responsibilities

• Coordinate care for a group of patients identified using MiPCT guidelines.
• Identify targeted high-risk populations within the site per PCP referral, risk stratification, and patient lists.
• Manage a caseload of approximately 150 complex patients, with 30–50 actively engaged.
• Assess health care, education, and psychosocial needs of patient/family.
• Collaborate with PCP to develop/update an individualized plan of care within the NextGen template.
• Provide targeted interventions to avoid hospitalizations and ED visits.
• Coordinate care across settings and assist patients/families with care options.
• Provide self-management support to patients/families to build self-care capacity.
• Work with RN team members on additional roles as needed.
• Implement infection prevention protocols and monitor outcomes.
• Provide follow-up after transitions and post-hospital care.
• Plan and evaluate infection control measures and policies.
• Investigate outbreaks and educate staff on infection control.
• Remain updated on procedures and CDC guidelines.
• Support corrective action plans and surveillance for infection control program.

Skills

Care coordination

Infection control

EHR (NextGen)

Patient education

Education

Associates Degree in Nursing

Bachelor Degree in Nursing (BSN)

RN licensure in Michigan

Job description

The RN Complex Care Manager functions as the lead in an organized, multidisciplinary, patient-centered care team, and assures quality, cost-effective care for the identified patient population. Manages the course of patient treatment plans, coordinates care with medical providers, nurses, and other staff ensuring quality patient outcomes are achieved within established time frames and with efficient utilization of resources. Function as a contact person for patients, families, health care team members, community resources, and employees as necessary. Ensure adherence to clinic and departmental policies and procedures. Patient care assignments may include neonate, pediatric, adolescent, adult, and geriatric age groups.

Duties include

• Coordinate care for a group of patients identified using Michigan Primary Care Transformation (MiPCT) guidelines.

• Identify targeted high-risk populations within the site per PCP referral, risk stratification, and patient lists.
• Manage a caseload of approximately 150 complex patients, of which 30 to 50 are actively engaged.
• Assess the health care, education, and psychosocial needs of the patient/family. Use standardized assessment tools as needed.
• Collaborate with PCP to develop and update a comprehensive, individualized plan of care with targeted interventions and documents within the NextGen EHR Care Management template.
• Provides targeted interventions to avoid hospitalizations and emergency room visits.
• Coordinate care across setting and help patients/families understand health care options.
• Provide self-management support to patients/family with an emphasis on empowering the patient to build capacity for self-care.
• Team with other organization case managers for RN-only roles.
• Implement evidence-based systems of care and protocols that facilitate close monitoring of high-risk patients to prevent and/or intervene early during acute health exacerbations.
• Provide follow-up with patient/family when managed patients transition from one setting to another.
• Completes timely post-hospital follow up including medication reconciliation, scheduling of PCP follow-up appointments, and patient education on their condition, problem-solving, and access to PCP / BFHC.
• Plans, implements, and evaluates infection prevention and control measures
• Develops and revises infection control policies and procedures
• Investigate suspected outbreaks of infection and provide staff education
• Serves as a resource for problem-solving issues related to infection prevention
• Provides oversight on infection control risk assessment, prevention, and control strategies
• Remain updated on procedures, developments and ensures compliance with regulatory agencies, and follows CDC guidelines
• Completes APIC Certification
• Collaborates with the team to implement and monitor corrective action plans related to infection control
• Serves as surveillance lead for the infection control program

Qualifications:

• Current RN Licensure in Michigan; Associates Degree in Nursing; Bachelor Degree in Nursing (BSN) preferred; Minimum 5 years clinical nursing experience.
• Knowledge of provider community and community resources in the White Cloud area.
• Comprehensive knowledge of insurance company principles and outpatient delivery systems.
  

Family Health Care is an equal opportunity employer.