The Integrated case Manager for Population Health 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. 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.
AMBULATORY CASE MANAGER:
Principle duties, responsibilities, knowledge and skills as described in the general section above.
Specific duties and responsibilities related to ambulatory primary and specialty care case management:
- 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.
EDUCATION/EXPERIENCE REQUIRED:
Bachelor’s degree in nursing (BSN) or related professional field (i.e. social work, counseling, health education, etc.) or a Master’s Degree of Social Work (MSW)
Minimum two (2) 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
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
CERTIFICATIONS/LICENSURES REQUIRED:
Registered Nurse (RN) or a Licensed Social Worker (LMSW) with a valid, unrestricted State of Michigan license
For current employees, effective date 10/31/2019, Certification in Case Management (CCM) is required by December 2023
For new hires, certification must be obtained within three (3) years from date of hire
PREFERRED QUALIFICATIONS:
Experience in discharge planning, home health care, rehabilitative medicine, community health or managed care
Certification in Case Management (CCM) by the Commission for Case Management Certification (CCMC)
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