Henry Ford Health
RN/Social Worker Case Manager -Transition Care (Hybrid - Troy, MI) - Populance
Henry Ford Health, Troy, Michigan, United States, 48083
RN/Social Worker Case Manager – Transition Care (Hybrid – Troy, MI) – Populance
Join to apply for the
RN/Social Worker Case Manager – Transition Care (Hybrid – Troy, MI) – Populance
role at
Henry Ford Health
We are now hiring passionate & dedicated RN or Social Worker Case Managers to join a new Henry Ford Health company dedicated to advancing population health while lowering the total cost of care. The position supports the Transition Care Management team day hours (M-F) in a work‑from‑home format most days, with on‑site attendance for meetings and training in Troy, MI required. For more about Populance visit: https://www.populance.org and follow us on LinkedIn.
General Summary 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 through 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.
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.
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.
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.
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 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.
Additional Information
Organization: Populance
Department: Transition Care Mgt
Shift: Day Job
Union Code: Not Applicable
Seniority level: Mid‑Senior level
Employment type: Full‑time
Job function: Other
Industries: Hospitals and Health Care, Insurance, and Wellness and Fitness Services
Referrals increase your chances of interviewing at Henry Ford Health by 2x Get notified about new Social Care Worker jobs in
Troy, MI .
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RN/Social Worker Case Manager – Transition Care (Hybrid – Troy, MI) – Populance
role at
Henry Ford Health
We are now hiring passionate & dedicated RN or Social Worker Case Managers to join a new Henry Ford Health company dedicated to advancing population health while lowering the total cost of care. The position supports the Transition Care Management team day hours (M-F) in a work‑from‑home format most days, with on‑site attendance for meetings and training in Troy, MI required. For more about Populance visit: https://www.populance.org and follow us on LinkedIn.
General Summary 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 through 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.
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.
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.
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.
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 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.
Additional Information
Organization: Populance
Department: Transition Care Mgt
Shift: Day Job
Union Code: Not Applicable
Seniority level: Mid‑Senior level
Employment type: Full‑time
Job function: Other
Industries: Hospitals and Health Care, Insurance, and Wellness and Fitness Services
Referrals increase your chances of interviewing at Henry Ford Health by 2x Get notified about new Social Care Worker jobs in
Troy, MI .
#J-18808-Ljbffr