Transition of Care Lead/RN Complex Care Manager

Family Health Care•Baldwin, MI

10d

About The Position

Family Health Care is seeking a Transition of Care Lead/RN Complex Care Manager. The role provides care management and coordination for adult and pediatric patients with complex illnesses in a primary care setting, under minimal supervision. The position collaborates with primary care providers, specialists, members of the health care team, and patients and families to support quality, efficient, and cost-effective health care services. It creates and implements care plans, and coordinates, monitors, and evaluates those plans to optimize patients’ health status. Care plans incorporate evidence-based clinical guidelines, preventive guidelines, and protocols and are individualized, patient-centric, and intended to promote quality and efficiency in health care delivery. The position is based in Baldwin, Michigan, and is full-time and non-exempt. A full benefits package is offered.

Responsibilities

Monitor hospital and long-term-care admissions, discharges, and transfers for patients assigned to the clinic.
Create care plans for transitions to home and office transition-of-care appointments in conjunction with the patient's primary care provider.
Participate in and understand Patient Centered Medical Home activities within BFHC, serving as RN CM TOC Lead.
Serve as backup for the RN Complex Manager at each site when needed.
Work with primary care providers to manage identified patients with complex medical and psychological health problems requiring more intensive education and monitoring outside scheduled office visits.
Create, implement, coordinate, monitor, and evaluate individualized care plans to optimize patient health status and promote quality and efficiency.