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Aledade is seeking a Care Manager to support primary care practices through the Provider Delivered Care Management Program (PDCMP). In this remote role based in Michigan, you will work with care teams and patients to deliver telephone-based health coaching, quality improvement, and care coordination.
You will be responsible for providing patient education and self-management support tailored to individual learning styles, helping patients understand their chronic conditions and access appropriate care settings. You'll conduct comprehensive assessments covering medical, behavioral, pharmaceutical, and social needs, identifying gaps in care and barriers to improved health outcomes.
Key responsibilities include collaborating with primary care physicians and interdisciplinary teams to identify high-risk patients and design care plan interventions; participating in complex care rounds; and supporting implementation of Aledade's population health initiatives. You will use Aledade's proprietary population health tool (the "Aledade App") to manage high-risk patients using real-time data to identify high utilizers who could benefit from preventative and active management.
Additionally, you will provide clinical oversight to non-licensed support staff such as health coaches, patient navigators, and community health specialists, delegating supportive tasks as appropriate. You'll measure, improve, and maintain quality outcomes (clinical, financial, and functional) for individual patients and populations served, with a focus on reducing unnecessary hospital and specialist utilization.
The role involves sedentary work on telephone and computer with repetitive movements, and up to 10% travel within Michigan to office practices and staff retreats as needed.
Aledade is a public benefit corporation founded in 2014 and is the largest network of independent primary care in the country. The company operates a remote-first culture and offers comprehensive benefits including flexible work schedules, health/dental/vision insurance (80% paid), 21 days PTO in year one, 12 weeks paid parental leave, and stock options.
REQUIREMENTS:
- Must hold an active, unencumbered Michigan license as either a Registered Nurse (RN) or fully licensed Master Social Worker (LMSW)
- Must be a 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 QUALIFICATIONS:
- Familiarity with the healthcare community served or commitment to learn through on-the-ground networking and community assessment
- 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 structured problem-solving techniques
- Exceptional written and oral communication skills; ability to positively influence others with respect and compassion
- Strong work ethic built on proactivity, collaboration, and teamwork
- Committed to inquiry and listening practices
- Competent in electronic health records documentation
- Demonstrates curiosity about learning and receiving critical feedback for growth
