Transition of Care Lead/RN Complex Care Manager

Family Health Care•Pleasant Plains Township, MI

11d

About The Position

Family Health Care is seeking a Transition of Care Lead/RN Complex Care Manager to provide care management and care coordination for adult and pediatric patients with complex illnesses in a primary care setting, under minimal supervision. The role collaborates with primary care providers, specialists, other health care team members, and patients and families to support quality, efficient, and cost-effective care. The position creates and implements individualized, patient-centered care plans and coordinates, monitors, and evaluates their implementation to optimize patients’ health status. Care plans incorporate evidence-based clinical guidelines, preventive guidelines, and protocols. The role also monitors hospital and long-term care transitions and supports follow-up care, while serving as the RN Care Management Transition of Care Lead and providing backup for RN Complex Managers at clinic sites when needed.

Responsibilities

Monitor hospital and long-term care admission, discharge, and transfer reports 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.
Serve as RN Care Management Transition of Care Lead.
Provide backup for the RN Complex Manager at each site when needed.
Work with primary care providers to manage 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 support quality, efficient, and cost-effective care.