Case Manager - Population Health - 1.0 Full Time Day Shift - Henry Ford Hospital

EDUCATION/EXPERIENCE REQUIRED:

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

CERTIFICATIONS/LICENSURES REQUIRED:

• 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) or Accredited Case Manager (ACM) by the American Case Management. Required within three (3) years of hire. 
• Post-Acute experience with Skilled Nursing facilities as well as previous CM/SW experience. 

ADDENDUM III: POST ACUTE CARE CASE MANAGER

 Principle duties, responsibilities, knowledge and skills as described in the general section above.

 Further duties and responsibilities related to post-acute case management and discharge planning:

• Provides support and guidance to post-acute care providers working collaboratively as care team members for patients with complex social needs.
• Participating in care conferences as well as bedside assessments to ensure coordination of care with post-acute providers.

• Collaborates with external resources 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.
• Increasing awareness of services offered by health system to improve patient outcomes.
• Builds and maintains positive relationships with patients/families, post-acute providers and other team members to ensure discharge plans are successfully completed.