Care Manager - Inpatient - PRN

Mary Free Bed Rehabilitation Hospital•Grand Rapids, MI

About The Position

The Care Manager provides care management services to patients and families throughout the rehabilitation process, supporting optimal functioning, adjustment to disability, and effective transitions to post-inpatient services. The role conducts psychosocial assessments, provides education and advocacy, coordinates discharge planning and follow-up, and collaborates with patients, families, rehabilitation teams, external care managers, providers, and funding sources. The position also maintains current clinical practice through continuing education, research, and program development. This is a PRN inpatient resource position offering flexible, as-needed coverage with no guaranteed hours. The role may provide discipline-specific coverage across the Mary Free Bed System as requested, participate in staff orientation and training, supervise student internships as appropriate, and support program operations as assigned. The position requires a current Michigan professional license in the area of practice and three years of care management experience in a health care setting. A current Social Worker license is required for Social Worker applicants; limited-license candidates may be considered if supervision is not required.

Requirements

A Registered Nurse, Master of Social Work, or Master of Counseling degree from an accredited school; equivalent degrees are accepted if granted by an accredited school of care management.
Current professional license in the area of practice from the State of Michigan. Social Worker applicants must hold a current Social Worker license; limited-license candidates may be considered if supervision is not required.
Three years of experience as a care manager in a health care setting.
Competence in an identified area of clinical expertise.
Excellent verbal and written communication skills, with the ability to communicate clearly, concisely, and professionally.
Ability to work collaboratively and effectively with interdisciplinary team members and families.
Strong time-management and organizational skills; ability to work independently and make quality collaborative decisions within short timeframes.
Analytical and problem-solving skills, and ability to work efficiently under tight deadlines, high volumes, and multiple interruptions.
Ability to demonstrate knowledge and skills for age-appropriate patient care, including knowledge of growth and development across the lifespan and the ability to assess patient status and identify age-specific needs.

Nice To Haves

Experience working in acute rehabilitation.
Experience in interdisciplinary team management.

Responsibilities

Provide care management services to patients and families.
Conduct initial psychosocial assessments of patient and family functioning, adjustment to disability, health literacy, and coping skills.
Educate patients and families to facilitate adjustment, problem-solving, and development and implementation of discharge or transition plans.
Communicate with patients and families or supports to promote participation in developing and carrying out the plan of care.
Act as an internal case manager and liaison with external case managers, providers, and funding sources to support patient satisfaction, quality, and cost-effective outcomes.
Coordinate transitions from inpatient care to community-based services, including outpatient rehabilitation, home care, hospice, school, vocational rehabilitation, and counseling.
Oversee patient follow-up to support durable outcomes.
Document patient and family status, progress, and discharge status in evaluations, progress notes, and discharge summaries within established time standards.
Identify complex discharge and transition needs early and help patients and families obtain resources such as non-covered medications, home modifications, and non-funded equipment.
Help ensure access to needed primary care follow-up and medications at discharge, including assistance locating funding when appropriate.
Educate patients and families about evidence-based practices for managing complex or chronic conditions across the continuum of care to reduce rehospitalization.
Communicate patient and family needs, preferences, resources, funding issues, and transition status to the rehabilitation team.
Participate actively in inpatient team conferences and facilitate family conferences as appropriate.
Advocate for patients and maintain confidentiality; educate patients, families, and care team members about treatment options, community resources, insurance benefits, psychosocial concerns, and case management.
Promote patient self-advocacy, choice, and self-determination, and educate patients and families about appropriate use of health care services.
Support quality of care and cost effectiveness on a case-by-case basis.
Provide discipline-specific coverage within the Mary Free Bed System as requested.
Participate in orientation and training of new staff.
Supervise student internships as appropriate.
Support program operations as assigned.
Demonstrate excellent customer service, encourage and monitor appropriate standards of behavior, promote teamwork and direct communication, and handle confidential information discreetly and sensitively.
Contribute to quality improvement by identifying problems and seeking solutions, promoting patient and family satisfaction, and participating in departmental customer-service monitoring and reporting.
Maintain clinical practice through continuing education, research, and program development.