Care Manager, Michigan

Who We Are: Aledade PBC, a public benefit corporation, exists to empower the most transformational part of our health care landscape - independent primary care. We were founded in 2014, and since then, we've become the largest network of independent primary care in the country - helping practices, health centers and clinics deliver better care to their patients and thrive in value-based care. Additionally, by creating value-based contracts across a wide variety of health plans, we aim to flip the script on the traditional fee-for-service model. Our work strengthens continuity of care, aligns incentives and ensures primary care physicians are paid for what they do best - keeping patients healthy. If you want to help create a health care system that is good for patients, good for practices and good for society - and if you're eager to join a collaborative, inclusive and remote-first culture - you've come to the right place.   What Does This Mean for You? At Aledade PBC, you will be part of a creative culture that is driven by a passion for tackling complex issues with respect, open-mindedness and a desire to learn. You will collaborate with team members who bring a wide range of experiences, interests, backgrounds, beliefs and achievements to their work - and who are all united by a shared passion for public health and a commitment to the Aledade mission.   In addition to time off to support work-life balance and enjoyment, we offer the following comprehensive benefits package designed for the overall well-being of our team members:   Flexible work schedules and the ability to work remotely are available for many roles Health, dental and vision insurance paid up to 80% for employees, dependents and domestic partners Robust time-off plan (21 days of PTO in your first year) Two paid volunteer days and 11 paid holidays 12 weeks paid parental leave for all new parents Six weeks paid sabbatical after six years of service Educational Assistant Program and Clinical Employee Reimbursement Program 401(k) with up to 4% match Stock options And much more!   At Aledade PBC, we don’t just accept differences, we celebrate them! We strive to attract, develop and retain highly qualified individuals representing the diverse communities where we live and work. Aledade is committed to creating a diverse environment and is proud to be an equal opportunity employer. Employment policies and decisions at Aledade are based on merit, qualifications, performance and business needs. All qualified candidates will receive consideration for employment without regard to age, race, color, national origin, gender (including pregnancy, childbirth or medical conditions related to pregnancy or childbirth), gender identity or expression, religion, physical or mental disability, medical condition, legally protected genetic information, marital status, veteran status, or sexual orientation.

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.

Population health and/or telephonic/remote care managed care experience

Understanding of quality metrics

Knowledge and experience activating patients and teaching self-management skills

Experience working with vulnerable populations across the lifespan (geriatrics, minorities, behavioral health)

Ability to navigate ambiguity with the aid of structured problem-solving techniques

Exceptional communication skills, both written and oral, ability to positively influence others with respect and compassion

Strong work ethic built on a foundation of proactivity, collaboration, and teamwork

Committed to the practice of inquiry and listening

Competent documenting in electronic health records

Demonstrates curiosity of learning and receiving critical feedback to further growth and development

Physical Requirements:

Sedentary work on telephone and computer with repetitive movements

Finger dexterity

Proficient communicative, auditory, and visual skills

Ability to travel up to estimated 10% as needed to office practices and staff retreats within Michigan as appropriate