Case Manager-Ambulatory/Transition of Care (Hybrid - Troy, 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 a passionate and dedicated RN or Social Worker Case Manager to join a new Henry Ford Health company dedicated do advancing population health, while lowering the total cost of care.  This position will be working with the Transition of Care (TOC) team day hours in a mostly work from home capacity, with the ability to attend in person company meetings in Troy, MI as scheduled.

GENERAL SUMMARY:

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 through 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.

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.
• 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.
• Maintains availability to patient/family/caregiver as a resource to facilitate communication among the multidisciplinary team and to monitor services rendered.  Remains involved until the patient achieves the planned level of functional health or closure criteria are met.
• 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.
• Facilitates 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.
• Advocates 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.
• Collaborates with appropriate members of the patient’s treatment/care team to co-manage patients with complex medical and social needs.
• 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.
• 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.
• Performs other duties as assigned.