RN Case Manager (Hybrid/Troy, MI) - Populance

Henry Ford Health•Troy, MI

5d•Hybrid

About The Position

The Populance Case Manager is an interdependent member of the patient-centered care team responsible for the collaborative practice of assessment, planning, facilitation, care coordination, evaluation and advocacy for options and services to meet an individual’s and family’s comprehensive health care needs though communication and available resources to promote patient safety, quality of care and cost-effective outcomes. The Case Manager addresses the needs of patients who have experienced a critical event or diagnosis that requires complex management strategies and/or the extensive use of resources to optimize health outcomes along the care continuum.

Requirements

Bachelor's degree in nursing.
Minimum 3 years of clinical experience.
Registered Nurse (RN) with a valid, unrestricted State of Michigan license.
Experience in discharge planning, home health care, rehabilitative medicine, community health, or managed care.
Knowledge of Medicare and Medicaid regulations and case management principles.
Knowledge of medical ethics and legal implications related to case management.
Well versed in facilitating community resources to meet the needs of diverse populations.
Excellent customer service and interpersonal skills including the ability to interact with internal and external customers and all levels of the organization.
Strong computer skills and knowledge.

Nice To Haves

Certification in Case Management (CCM) by the Commission for Case Management Certification (CCMC) or Accredited Case Manager (ACM) by the American Case Management Association required within 3 years of hire.

Responsibilities

Conduct assessments of patient’s and family/caregiver’s biomedical, psychological, social, and functional needs to gage the potential impact on recovery.
Develop, implement, monitor, and modify a patient-centered plan of care through an interdisciplinary and collaborative team process, in conjunction with the patient, the caregivers and the healthcare team.
Maintain availability to patient/family/caregiver as a resource to facilitate communication among the multidisciplinary team and to monitor services rendered. Remain involved until the patient achieves the planned level of functional health or closure criteria are met.
Utilize professional judgment, critical thinking, motivational interviewing, and self-management techniques to assist patients in overcoming barriers to goal achievement.
Provide counseling and interventions related to treatment decisions and end of life issues including Advanced Care Planning.
Provide coordination as necessary to ensure patients seamlessly and safely transition between care settings.
Facilitate referrals for additional medical and ancillary services, including home healthcare, infusion therapy, palliative care, hospice, inpatient extended care facilities, and medical equipment and supplies, as needed.
Advocate for appropriate delivery of services within the patient’s health plan benefit structure.
Participate in the development of cost savings opportunities through the identification of quality management, case management, and multi-disciplinary processes.
Coordinate and assist in the development of innovative alternative care delivery mechanisms to meet special needs of patient.
Collaborate with appropriate members of the patient’s treatment/care team to co-manage patients with complex medical and social needs.
Facilitate interdisciplinary collaborative case conferences that result in the development and progression of a multidimensional plan of care for each patient.
Provide support and guidance to community health workers working as care team members for patients with complex social needs.
Provide support and guidance to post-acute care providers working collaboratively as care team members for patients with complex social needs.
Collaborate with external resources/agencies and post-acute care health teams to optimize patient outcomes and improve patient care experience when transitioning to the next level of care or home.
Plan and participate in process improvement activities designed to reduce risk, inclusive of data collection, analysis, and follow-up intervention activities.
Facilitate interventions in cases involving child abuse and neglect, domestic violence, elder abuse, institutional abuse, and sexual assault.
Support department-based goals which contribute to the success of the organization.
Maintain a level of competency and knowledge related to case management, disease processes and acute illnesses to assist with care coordination.
Maintain electronic medical records including professional, clinical documentation to ensure continuity of care and compliance to regulatory requirements (e.g., HIPAA, NCQA).
Collect, analyze, and interpret data for trending, reference, problem identification and problem solving.