RN Complex Care Navigator for High-Risk Patients

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

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.