Transition of Care Lead/RN Complex Care Manager

Family Health Care is seeking candidates for its Transition of Care Lead/RN Complex Care Manager position!

General Function:

Provides care management and care coordination for adult and pediatric patients with complex illness, in the primary care setting, under minimal supervision. Serves in an expanded health care role to collaborate with PCP, specialists, members of the health care team, and patients/families to ensure the delivery of quality, efficient, and cost-effective health care services. Creates and implements care plans, coordinates, monitors and evaluates implementation of care plans with the goal of optimizing the patient’s health status. Integrates evidence-based clinical guidelines, preventive guidelines, and protocols, in the development of individualized care plans that are patient-centric, promoting quality and efficiency in the delivery of health care.

Primary Responsibilities

• Monitors hospital/long term care admissions, discharges and transfers reports of patients assigned to the clinic and creates necessary care plans for transition to home and office TOC appointments in conjunction with the patient's primary care provider.
• Actively participates in and understands Patient Centered Medical Home (PCMH) activities within BFHC and serves as RN CM TOC Lead.
• Serves as back up for the RN Complex Manager at each site if needed.
• RN Care Manager works with the primary care providers in management of identified patients with complex medical and psychological health problems that require more intense education and monitoring outside of the scheduled office visits.

Location: Baldwin , MI

Employment Type: Full Time

Exempt/Non-Exempt: Non-Exempt

Benefits: Full benefits package

Family Health Care is an Equal Opportunity Employer.