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 using resources efficiently. The manager serves as a contact for patients, families, health care team members, community resources, and employees, and ensures adherence to clinic and departmental policies and procedures. Patient assignments may include neonate, pediatric, adolescent, adult, and geriatric age groups. The position also leads infection prevention and control activities, including developing and revising policies and procedures, investigating suspected outbreaks, educating staff, overseeing risk assessment and prevention strategies, ensuring compliance with regulatory agencies and CDC guidelines, and serving as the infection-control surveillance lead. The role completes APIC Certification and collaborates with the team on corrective action plans related to infection control.

Requirements

Current RN licensure in Michigan.
Associate degree in Nursing.
Minimum of 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 based on PCP referrals, risk stratification, and patient lists.
Manage a caseload of approximately 150 complex patients, including 30 to 50 actively engaged patients.
Assess patients’ and families’ health care, education, and psychosocial needs, using standardized assessment tools as needed.
Collaborate with PCPs to develop and update comprehensive, individualized care plans 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 that empowers patients to build 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 during 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 PCP follow-up appointments, and educating patients about their condition, 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.