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.
- 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
$70,000 - $87,000 a year
Salary Range: $70,000 to $87,000 base + bonus + equity
Compensation for the role will depend on a number of factors, including a candidate’s qualifications, skills, competencies and experience.
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.
We may use automated tools, including artificial intelligence (AI), to help organize and evaluate application materials. These tools support our recruiters and hiring managers by helping manage large applicant pools. Human judgment plays an essential role in our hiring process, including in the oversight and use of any automated tools. If you would like more information about our screening and hiring process, please contact us.
Our Commitment to Authenticity. We use Endorsed, a fraud detection tool, to validate the authenticity of applications and protect against identity fraud. This ensures we are connecting with real people and allows us to prioritize genuine candidates.
When you apply to a job on this site, the personal data contained in your application will be collected by Aledade PBC using Lever, a cloud services provider located in the United States. Lever is engaged by Aledade PBC to help manage its recruitment and hiring processes. For more information about how your personal data will be processed by Aledade PBC and any rights you may have, please review Aledade PBC’s Candidate Privacy Notice.
By applying for this job, you agree to Aledade's Applicant Privacy Policy available at https://www.aledade.com/privacy-policy-applicants
If you have any questions about our privacy practices, please contact [email protected].
Our Commitment to Authenticity. We use Endorsed, a fraud detection tool, to validate the authenticity of applications and protect against identity fraud. This ensures we are connecting with real people and allows us to prioritize genuine candidates.
When you apply to a job on this site, the personal data contained in your application will be collected by Aledade PBC using Lever, a cloud services provider located in the United States. Lever is engaged by Aledade PBC to help manage its recruitment and hiring processes. For more information about how your personal data will be processed by Aledade PBC and any rights you may have, please review Aledade PBC’s Candidate Privacy Notice.
By applying for this job, you agree to Aledade's Applicant Privacy Policy available at https://www.aledade.com/privacy-policy-applicants
If you have any questions about our privacy practices, please contact [email protected].
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