RN/Social Worker Case Manager Ambulatory (Hybrid - Detroit, MI) - Populance

Are you fulfilled by supporting doctors, hospitals and health plans to make sure patients get the right care at the right place and the right time? We are now hiring passionate & dedicated RN or Social Worker Case Managers to join Populance - a Henry Ford Health company dedicated to advancing population health, while lowering the total cost of care. To learn more about Populance, visit our website at https://www.populance.org/

This position will be day hours (M-F ) working in clinical practices, with some remote work day options.

GENERAL SUMMARY:

The Case Manager is an interdependent member of the patient-centered care team or treatment 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 through communication and available resources to promote patient safety, quality of care and cost-effective outcomes. Addresses the needs of patients who have experienced a critical event or diagnosis that requires complex management strategies and the extensive use of resources to optimize health outcomes along the care continuum. Provides services to patients from ambulatory, inpatient or health plan settings.

PRINCIPLE DUTIES AND RESPONSIBILITIES:

• Conducts a comprehensive 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 as part of the care team through advocacy, ongoing communication, health education, identification of resources and service facilitation.
• Utilizes professional judgment, critical thinking, motivational interviewing, 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.
• Provides coordination as necessary to ensure patients seamlessly and safely transition between care settings.
• 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 co-manage 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.
• Facilitates interdisciplinary collaborative case conferences that result in the development and progression of a multidimensional plan of care for each patient.
• Provides support and guidance to community health workers working as care team members for patients with complex social needs.
• Provides support and guidance to post-acute care providers working collaboratively as care team members for patients with complex social needs.
• Collaborates 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.
• Plans and participates in process improvement activities designed to reduce risk, inclusive of data collection, analysis, and follow-up intervention activities.
• 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.