The Complex Care Manager provides care management and care coordination for adult and pediatric patients with complex illness, in the primary care setting, under minimal supervision. In partnership with the primary care practice leadership team, the Complex Care Manager leads care management within the team through process improvement, workflow redesign, providing assistance with training, and delegating to other members of the team. Serves in an expanded health care role to collaborate with specialists, members of the health care team, and patients/families to ensure the delivery of quality, efficient, and cost-effective health care services. Assesses plans, implements, coordinates, monitors and evaluates all options and services 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.
Manages a caseload of approximately 150 complex patients; of which 30 to 50 patients are actively followed by complex care manager. Provides targeted interventions to avoid hospitalization and emergency room visits. Coordinates care across settings and helps patient/families understand health care options. Infrequent, but possibility of home visits.
- Bachelor’s degree or higher, in clinical field.
- Current Michigan Registered Nurse, Nurse Practitioner, Physician Assistant or Master of Social Work License.
- Knowledge of chronic conditions, evidence based guidelines, prevention, wellness, health risk assessment, and patient education.
- Critical thinking skills and ability to analyze complex data sets.
- Ability to manage complex clinical issues utilizing assessment skills and protocols.
- Excellent assessment and triage skills.
- Ability to implement evidence base interventions and protocols for chronic conditions. Experience as participant in continuous quality improvement.
- General computer knowledge and capability to use computer.
- Three years of experience with adult medicine and pediatric patients in primary care/ambulatory care, home health agency, skilled nursing facility, or hospital medical-surgical setting, within the past five years. Case Management or Care management experience.
- Experience in self-management support.
One of the largest, most comprehensive health care providers north of metro Detroit, Covenant HealthCare is a non-profit health system that...