RN Complex Care Manager

Family Health Care•White Cloud, MI

About The Position

The RN Complex Care Manager leads an organized, multidisciplinary, patient-centered care team and ensures quality, cost-effective care for an identified patient population. The role manages patient treatment plans and coordinates with medical providers, nurses, and other staff to achieve quality outcomes within established time frames while efficiently using resources. The position serves as a contact for patients, families, health care team members, community resources, and employees as needed, and ensures adherence to clinic and departmental policies and procedures. Patient assignments may include neonate, pediatric, adolescent, adult, and geriatric age groups. The role coordinates care for patients identified under Michigan Primary Care Transformation (MiPCT) guidelines, identifies high-risk populations, and manages a caseload of approximately 150 complex patients, including 30 to 50 actively engaged patients. It assesses patient and family health care, education, and psychosocial needs; collaborates with primary care providers on individualized care plans; delivers interventions to prevent hospitalizations and emergency room visits; and supports transitions between care settings and patient self-management. The position also leads infection prevention and control activities, including planning and evaluating measures, developing and revising policies and procedures, investigating suspected outbreaks, educating staff, overseeing infection control risk assessment and prevention strategies, monitoring corrective action plans, and serving as the surveillance lead. The role stays current with procedures and developments, ensures regulatory compliance, follows CDC guidelines, and completes APIC Certification.

Requirements

Current RN licensure in Michigan.
Associate degree in Nursing.
Minimum 5 years of clinical nursing experience.
Knowledge of the provider community and community resources in the White Cloud area.
Comprehensive knowledge of insurance company principles and outpatient delivery systems.

Nice To Haves

Bachelor of Science in Nursing (BSN) preferred.

Responsibilities

Coordinate care for a group of patients identified using Michigan Primary Care Transformation (MiPCT) guidelines.
Identify targeted high-risk populations at the site through primary care provider referrals, risk stratification, and patient lists.
Manage a caseload of approximately 150 complex patients, of whom 30 to 50 are actively engaged.
Assess the health care, education, and psychosocial needs of patients and families, using standardized assessment tools as needed.
Collaborate with primary care providers to develop and update comprehensive, individualized plans of care with targeted interventions, documenting them in the NextGen EHR Care Management template.
Provide targeted interventions to help avoid hospitalizations and emergency room visits.
Coordinate care across settings and help patients and families understand health care options.
Provide self-management support to patients and families, emphasizing patient capacity for self-care.
Team with other organization case managers for RN-only roles.
Implement evidence-based systems of care and protocols to monitor high-risk patients and prevent or intervene early in acute health exacerbations.
Follow up with patients and families when managed patients transition between care settings.
Complete timely post-hospital follow-up, including medication reconciliation, scheduling primary care follow-up appointments, and patient education about conditions, problem-solving, and access to PCP/BFHC.
Plan, implement, and evaluate infection prevention and control measures.
Develop and revise infection control policies and procedures.
Investigate suspected infection outbreaks and provide staff education.
Serve as a resource for resolving infection prevention issues.
Oversee infection control risk assessment, prevention, and control strategies.
Stay updated on procedures and developments, ensure compliance with regulatory agencies, and follow CDC guidelines.
Complete APIC Certification.
Collaborate with the team to implement and monitor corrective action plans related to infection control.
Serve as surveillance lead for the infection control program.
Ensure adherence to clinic and departmental policies and procedures.