RN Complex Care Manager - Lead Integrated Patient Care

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

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.