Care Manager, Michigan

The Care Manager will work with primary care practices as a part of the Provider Delivered Care Management Program (PDCMP). The Care Manager collaborates with the care team within each practice and leverages Aledade’s interdisciplinary care team to provide telephone-based health coaching, quality improvement, and care coordination. The Care Manager works closely with patients to support them in becoming active in their health care by better understanding their chronic conditions, helping them access care in the most appropriate setting, and improving quality of care. Care Managers utilize Aledade’s proprietary population health tool, the “Aledade App” to manage high-risk patients, using real-time data to identify and intervene on high utilizers who could benefit from more preventative and active management. Location Requirement: This is a remote role within Michigan. Candidates must be based in the state of Michigan to be considered. Primary Duties - Provide education and self-management support based on the patient’s unique learning style; Work with the patient and their caregiver to increase their self-efficacy and ability to play a central role in their care; Coordinate care by serving as the advocate and resource for the patient, their family, and their physician, building effective relationships in the community and across the continuum of care; provide patients with care transition planning support and follow up. - Conduct comprehensive assessments that include the medical, behavioral, pharmaceutical and social needs of the patient, identify and address gaps in care and barriers to attaining improved health; Assess the patient’s knowledge of their clinical condition. - Collaborate with the patient’s primary care physician and care team if applicable, to identify high-risk patients and design appropriate care plan interventions; participate in and help facilitate periodic complex care rounds with interdisciplinary care team.

- Support implementation of Aledade initiatives that support population health care management (vendors for end of life care, virtual behavioral health, etc. ). Measure, improve and maintain quality outcomes (clinical, financial, and functional) for individual patients and the population served; understand the requirements and intent of the Provider Delivered Care Management, and develop and execute care plans focused on reducing unnecessary hospital and specialist utilization and improving quality. - Provide clinical oversight to non-licensed support staff (e. g. health coaches, patient navigators, community health specialists, etc. ) and delegate supportive tasks as appropriate. Minimum Qualifications: - Must hold an active, unencumbered Michigan license as either a Registered Nurse (RN) or a fully licensed Master Social Worker (LMSW) - Resident of Michigan - 3-5 years of direct healthcare experience, preferably in home health, ambulatory care, community public health, case management, or care coordination across multiple settings with multiple providers Preferred KSA’s: - Familiarity with the healthcare community we are serving or commitment to learn and understand through on the ground networking, community assessment, etc.