Case Manager-Pallative Care, Detroit Campus, Full Time

Behavioral Health
1913978 Requisition #

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 though communication and available resources to promote patient safety, quality of care and cost effective outcomes. (Case Management Society of America , 2016)  In this capacity the Case Manager 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.  The Case Manager provides services to patients from ambulatory, inpatient or health plan settings.

Principle duties, responsibilities, knowledge and skills:
·  Provides counseling to patients with serious illness, and their families, to help with coping psychological distress, and existential stress.
·       Performs caregiver assessment and provides interventions for needs identified
·       Provides counseling and education to help families talk to children about serious illness and death. Accesses and mobilizes community resources to meet the needs of children coping with the illness or death of a loved one.
·       Provides extensive counseling to assist in advance care planning and completing an advance directive.
·       Provides counseling to assist in completing a simple will.
·       Leads team debriefs after stressful clinical events and helps plan team wellness activities.
·       Provides bereavement resources to families and performs bereavement follow-up calls to high risk family members for patients who did not enroll in hospice
·       Serves as a liaison for community based and home-based palliative care.  Develops expertise in palliative care resources in the community and makes recommendations to primary case manager to best meet patient needs.
·       Educates palliative medicine team members, fellows, and residents on the psychosocial aspects of palliative care through formal didactic presentations and informal teaching sessions.
·       Collaborate with palliative medicine interdisciplinary teams to lead and participate in patient/family meetings to discuss serious news and goals of care.
  • Conducts a comprehensive assessment of patient 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. 
  • 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.
  • Performs other duties as assigned.


  • Bachelor degree (or higher) in nursing or related professional field (i.e. social work, counseling, health education, etc.).
  • 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, community health 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 patient needs simultaneously.
  • Strong sense of compassion with the ability to successfully advocate for patients and their families.


  • 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) preferred.
    • For current employees, effective date 10/31/2019, certification is required by December, 2023.
    • For new hires, certification must be obtained within 3-years from date of hire.


       Under the leadership of President and CEO Wright L. Lassiter, III, Henry Ford Health System is a

       $6 billion integrated health system comprised of six hospitals, a health plan, and 250+ sites

       including medical centers, walk-in and urgent care clinics, pharmacy, eye care facilities and

       other healthcare retail. Established in 1915 by auto industry pioneer Henry Ford, the health system

       now has 32,000 employees and remains home to the 1,900-member Henry Ford Medical Group, one

       of the nation’s oldest physician groups. An additional 2,200 physicians are also affiliated with the

       health system through the Henry Ford Physician Network. Henry Ford is also one of the region’s  

       major academic medical centers, receiving between $90-$100 million in annual research funding and

       remaining Michigan’s fourth largest NIH-funded institution. Also an active participant in medical

       education and training, the health system has trained nearly 40% of physicians currently practicing

       in the state and also provides education and training for other health professionals including nurses,

       pharmacists, radiology and respiratory technicians. visit


       Whether it's offering a new medical option, helping you make healthier lifestyle choices or

       making the employee enrollment selection experience easier, it's all about choice.  Henry

       Ford Health System has a new approach for its employee benefits program - My Choice

       Rewards.  My Choice Rewards is a program as diverse as the people it serves.  There are

       dozens of options for all of our employees including compensation, benefits, work/life balance

       and learning - options that enhance your career and add value to your personal life.  As an

       employee you are provided access to Retirement Programs, an Employee Assistance Program

       (Henry Ford Enhanced), Tuition Reimbursement, Paid Time Off, Employee Health and Wellness,                 and a whole host of other benefits and services.  Employee's classified as contingent status are not         eligible for benefits.    

      Equal Employment Opportunity/Affirmative Action Employer

        Equal Employment Opportunity / Affirmative Action Employer Henry Ford Health System is

        committed to the hiring, advancement and fair treatment of all individuals without regard to

        race, color, creed, religion, age, sex, national origin, disability, veteran status, size, height,

        weight, marital status, family status, gender identity, sexual orientation, and genetic information,

        or any other protected status in accordance with applicable federal and state laws.

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