RN Complex Care Manager

baldwinfamilyhealthcare; White Cloud (MI); On-site; USD 75,000 - 105,000; Full time

Job summary

Family Health Care seeks an RN Complex Care Manager to lead a multidisciplinary team and ensure quality, cost-effective care for high-risk patients in White Cloud, MI. You will manage approximately 150 complex cases, coordinate with PCPs, and develop individualized care plans within the NextGen EHR.

Roles include infection control oversight and post-discharge follow-up. The position requires MI RN licensure, strong care coordination, and experience in outpatient systems; BSN preferred.

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.

Responsibilities

• Coordinate care for patients identified using MiPCT guidelines.
• Manage a caseload of approximately 150 complex patients, with 30–50 actively engaged.
• Assess health care, education, and psychosocial needs of patient/family using standardized tools.
• Collaborate with PCP to develop/update an individualized plan of care in NextGen Care Management template.
• Provide targeted interventions to avoid hospitalizations and ER visits.
• Coordinate care across settings and help patients/families understand health care options.
• Provide self-management support to empower patients for self-care.
• Infection prevention policy development, training, and surveillance leadership.
• Complete post-hospital follow-up including medication reconciliation and PCP scheduling.
• Ensure adherence to clinic policies and regulatory guidelines.

Skills

Care coordination

Patient advocacy

Interdisciplinary teamwork

Infection control awareness

Education

Associate's Degree in Nursing

Bachelor's Degree in Nursing (BSN) preferred

Current RN Licensure in Michigan

Tools

NextGen EHR

Outpatient care systems

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.