The RN Complex Care Manager leads an organized, multidisciplinary, patient-centered care team and ensures quality, cost-effective care for the identified patient population. Manages the course of patient treatment plans and coordinates care with medical providers, nurses, and other staff, ensuring quality patient outcomes are achieved within established time frames and efficiently utilizing resources. Function as a contact person for patients, families, health care team members, community resources, and employees as necessary. Ensure adherence to clinic and departmental policies and procedures. Patient care assignments may include neonate, pediatric, adolescent, adult, and geriatric age groups.
Duties include:
- Coordinate care for a group of patients identified using Michigan Primary Care Transformation (MiPCT) guidelines
- Identify targeted high-risk populations within the site per PCP referral, risk stratification, and patient lists
- Manage a caseload of approximately 150 complex patients, of which 30 to 50 are actively engaged
- Assess the health care, education, and psychosocial needs of the patient/family. Use standardized assessment tools as needed
- Collaborate with PCP to develop and update a comprehensive, individualized plan of care with targeted interventions and documents within the NextGen EHR Care Management template
- Provides targeted interventions to avoid hospitalizations and emergency room visits
- Coordinate care across settings and help patients/families understand health care options
- Provide self-management support to patients/family, emphasizing empowering the patient to build capacity for self-care
- Team with other organization case managers for RN-only roles
- Implement evidence-based systems of care and protocols that facilitate close monitoring of high-risk patients to prevent and/or intervene early during acute health exacerbations
- Provide follow-up with patient/family when managing patients' transition from one setting to another
- Completes timely post-hospital follow-up, including medication reconciliation, scheduling PCP follow-up appointments, patient education on their condition, problem-solving, and access to PCP / BFHC
- Plans, implements and evaluates infection prevention and control measures
- Develops and revise infection control policies and procedures
- Investigate suspected outbreaks of infection and provide staff education
- Serves as a resource for problem-solving issues related to infection prevention
- Provides oversight on infection control risk assessment, prevention, and control strategies
- Remain updated on procedures, developments and ensure compliance with regulatory agencies, and follow CDC guidelines
- Completes APIC Certification
- Collaborates with the team to implement and monitor corrective action plans related to infection control
- Serves as surveillance lead for the infection control program
Family Health Care is an equal opportunity employer.
