Case Manager (Registered Nurse Or Licensed Social Worker) - Full Time

GENERAL SUMMARY:
The Case Manager is a member of the hospital or specialty-based patient-centered care team or treatment team responsible for the collaborative practices of identification, assessment, planning, facilitation, care coordination, evaluation and advocacy for options and services to meet an individual's and family's health care needs. The goals of the Case Manager are to promote patient safety, quality of care and cost-effective outcomes. The Case Manager provides effective discharge planning services that support a safe transition to the next level of care and addresses the needs of patients who have experienced a critical event or diagnosis that requires management strategies to optimize health outcomes along the care continuum.
PRINCIPLE DUTIES AND RESPONSIBILITIES:

• Conducts an assessment of patient's and family/caregiver's biomedical, psychological, social, and functional needs to gage the potential impact on recovery.
• Develops personalized patient-centered care plans aimed at optimizing the patient's care experience.
• Engages patients and their families/caregivers as part of the care team through advocacy, ongoing communication, identification of resources and service facilitation.
• Utilizes critical thinking skills and self-management techniques to assist patients in overcoming barriers to goal achievement.
• Provides counseling and interventions related to treatment decisions and end of life issues including Advanced Care Planning. Coordinates/facilitates patient care progression throughout the continuum by working collaboratively and maintaining active communication with members of the multi-disciplinary team to effect timely, appropriate patient management and a seamless and safe transition between care settings.
• Anticipates and collaborates with the multidisciplinary team to address psychosocial and/or financial barriers that may impact or delay the discharge plan or interfere with medical compliance.
• Participates in and conducts inter-professional, patient, family and caregiver meetings that promote shared decision making.
• As subject matter expert for post-acute care discharge options, assists the treatment team, patient, and family in selecting the appropriate discharge disposition and consults with internal and external healthcare providers, agencies, and payers.
• Advocates for appropriate delivery of services within the patient's health plan benefit structure.
• Collaborates with appropriate members of the patient's treatment/care team to comanage patients with complex medical and social needs. Facilitates interdependent collaborate care conferences.
• Continually evaluates the patient's response to the care/treatment plan making modifications when necessary.
• Plans and participates in process improvement activities designed to reduce risk and increase safety.
• Facilitates interventions in cases involving child abuse and neglect, domestic violence, elder abuse, institutional abuse, and sexual assault.
• Supports department-based goals which contribute to the success of the organization.

EDUCATION/EXPERIENCE REQUIRED:

• Bachelor's degree in nursing or a Master's degree of Social Work.
• Minimum (3) three years of clinical experience.
• Excellent verbal communication and written documentation skills.
• Excellent customer service and interpersonal skills including the ability to interact with internal and external customers and all levels of the organization.
• Strong problem-solving, analytical, and decision-making skills.
• Strong computer skills and knowledge.
• Experience in discharge planning, home health care, rehabilitative medicine, or managed care preferred.
• Knowledge of preventive service guidelines, clinical practice guidelines, behavior change theory, Medicare and Medicaid regulations and case management principles.
• Knowledge of medical ethics and legal implications related to case management.
• Understanding of social determinants of health and their impact on a patient's wellbeing.
• Well versed in facilitating community resources to meet the needs of diverse populations.
• Strong organizational, planning and implementation skills with the ability to handle multiple complex patients' needs simultaneously.
• Strong sense of compassion with the ability to successfully advocate for patients and their families.

CERTIFICATIONS/LICENSURES REQUIRED:

• Registered Nurse (RN) or a Licensed Social Worker (LMSW) with a valid, unrestricted State of Michigan license.
• Certification in Case Management (CCM) by the Commission for Case Management Certification (CCMC) or Accredited Case Manager (ACM) by the American Case Management Association preferred.