RN Transition of Care Lead & Complex Care Manager

Family Health Care; Baldwin Township (MI); On-site; USD 65,000 - 95,000; Full time

Benefits offered by this job

Full benefits package

Job summary

Family Health Care in Baldwin, Michigan, is seeking a Transition of Care Lead/RN Complex Care Manager to provide care management for adults and children with complex illnesses in a primary care setting, under minimal supervision. The role focuses on creating and implementing individualized care plans, coordinating care with PCPs and specialists, and monitoring progress to improve health outcomes.

You will collaborate with the health care team to ensure high-quality, efficient, and cost-effective

Responsibilities

• Monitors hospital/long term care admissions, discharges and transfers reports of patients assigned to the clinic and creates necessary care plans for transition to home and office TOC appointments in conjunction with the patient's primary care provider.
• Actively participates in and understands Patient Centered Medical Home (PCMH) activities within BFHC and serves as RN CM TOC Lead.
• Serves as back up for the RN Complex Manager at each site if needed.
• RN Care Manager works with the primary care providers in management of identified patients with complex medical and psychological health problems that require more intense education and monitoring outside of the scheduled office visits.

Job description

Family Health Care in Baldwin, Michigan, is seeking a Transition of Care Lead/RN Complex Care Manager to provide care management for adults and children with complex illnesses in a primary care setting, under minimal supervision. The role focuses on creating and implementing individualized care plans, coordinating care with PCPs and specialists, and monitoring progress to improve health outcomes.

You will collaborate with the health care team to ensure high-quality, efficient, and cost-effective