Henry Ford Health - Troy, MI
posted about 1 month ago
Full-time - Mid Level
Hybrid - Troy, MI
Ambulatory Health Care Services
About the position
The Case Manager in Post Acute Care is a vital member of the patient-centered care team, responsible for assessing, planning, facilitating, coordinating, and advocating for comprehensive health care services to meet the needs of patients and their families. This role focuses on optimizing health outcomes for patients who have experienced critical events or diagnoses, ensuring seamless transitions between care settings, and promoting patient safety and quality of care through effective communication and resource utilization.
Responsibilities
- Conduct comprehensive assessments of patients' and families' biomedical, psychological, social, and functional needs.
- Develop personalized patient-centered care plans to enhance the patient's care experience.
- Engage patients and families in the care process through advocacy, communication, and health education.
- Utilize professional judgment and motivational interviewing 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.
- Coordinate care to ensure safe transitions between different care settings.
- Advocate for appropriate service delivery within the patient's health plan benefit structure.
- Collaborate with treatment team members to co-manage patients with complex needs.
- Facilitate interdisciplinary collaborative case conferences to develop and progress care plans.
- Support community health workers and post-acute care providers in managing patients with complex social needs.
- Collaborate with external resources to optimize patient outcomes during transitions of care.
- Participate in process improvement activities to reduce risk and enhance patient care.
Requirements
- Bachelor's degree in nursing or a related field, or a Master's degree in Social Work.
- Minimum of 3 years of clinical experience in a relevant field.
- Excellent verbal and written communication skills.
- Strong customer service and interpersonal skills.
- Problem-solving, analytical, and decision-making skills.
- Proficient computer skills and knowledge.
- Experience in discharge planning, home health care, or community health preferred.
- Knowledge of Medicare and Medicaid regulations and case management principles.
- Understanding of social determinants of health and their impact on patient well-being.
Nice-to-haves
- Experience in rehabilitative medicine or managed care.
- Knowledge of preventive service guidelines and clinical practice guidelines.
- Familiarity with behavior change theory and medical ethics.
Benefits
- Health insurance
- Dental insurance
- Tuition reimbursement
