RN/Social Worker Case Manager Ambulatory (Hybrid - Detroit, MI) - Populance

Henry Ford Health System; Detroit (MI); Hybrid; USD 60,000 - 80,000; Full time

Job summary

A leading health organization in Detroit is seeking dedicated RN or Social Worker Case Managers to join their team. This hybrid role involves working with patients to optimize care through assessment, planning, and advocacy. Candidates should possess strong problem-solving skills and a relevant degree. Join a passionate team focused on improving population health and patient outcomes.

Qualifications

• At least three years of clinical experience.
• Preferred experience in discharge planning and community health.

Responsibilities

• Conduct comprehensive assessments of patients' needs.
• Develop personalized, patient-centered care plans.
• Coordinate care transitions to ensure safety.

Skills

Customer Service

Problem Solving

Analytical Skills

Decision Making

Organizational Skills

Advocacy

Education

Bachelor’s degree in nursing

Master’s in Social Work

Tools

Computer Skills

Job description

RN/Social Worker Case Manager Ambulatory (Hybrid - Detroit, MI) - Populance

Are you fulfilled by supporting doctors, hospitals, and health plans to ensure patients receive the right care at the right time and place? We are hiring passionate & dedicated RN or Social Worker Case Managers to join Populance, a Henry Ford Health company dedicated to advancing population health while lowering the total cost of care. Learn more at https://www.populance.org/.

This position involves daytime hours (Monday-Friday) working in clinical practices, with some remote work options.

GENERAL SUMMARY:

The Case Manager is a key member of the patient-centered care team, responsible for assessment, planning, facilitation, care coordination, evaluation, and advocacy to meet patients' health needs through communication and available resources, promoting safety, quality, and cost-effective outcomes. The role addresses complex cases requiring extensive resource use across ambulatory, inpatient, or health plan settings.

PRINCIPLE DUTIES AND RESPONSIBILITIES:

• Conduct comprehensive assessments of biomedical, psychological, social, and functional needs of patients and families to gauge recovery impact.
• Develop personalized, patient-centered care plans to optimize care experience.
• Engage patients and families as part of the care team through advocacy, communication, health education, and resource facilitation.
• Use professional judgment, critical thinking, motivational interviewing, and self-management techniques to help patients overcome barriers.
• Provide counseling and interventions on treatment decisions and end-of-life issues, including Advanced Care Planning.
• Coordinate care transitions to ensure safety and continuity.
• Advocate within the patient's health plan benefit structure.
• Collaborate with treatment team members to co-manage patients with complex needs and facilitate interdisciplinary conferences.
• Continuously evaluate and modify care plans based on patient response.
• Lead interdisciplinary case conferences to develop comprehensive care plans.
• Support community health workers and post-acute care providers working with complex social needs.
• Coordinate with external resources and agencies to improve patient outcomes during care transitions.
• Participate in process improvement activities, including data collection and analysis.
• Handle interventions involving child abuse, domestic violence, elder abuse, institutional abuse, and sexual assault.
• Contribute to department and organizational goals.

EDUCATION/EXPERIENCE REQUIRED:

• Bachelor’s degree in nursing or related field (social work, counseling, health education) or a Master’s in Social Work.
• At least three years of clinical experience.
• Excellent customer service and interpersonal skills.
• Strong problem-solving, analytical, and decision-making skills.
• Proficiency in computer skills and knowledge.
• Preferred experience in discharge planning, home health, rehabilitative medicine, community health, or managed care.
• Knowledge of preventive and clinical practice guidelines, behavior change theories, Medicare/Medicaid regulations, and case management principles.
• Understanding of medical ethics, legal implications, and social determinants of health.
• Ability to facilitate community resources for diverse populations.
• Strong organizational and multitasking skills.
• Compassionate advocacy for patients and families.

CERTIFICATIONS/LICENSURES REQUIRED:

• Valid, unrestricted Michigan RN or LMSW license.
• Certification in Case Management (CCM or ACM) required within three years of hire.

This description outlines major duties but is not exhaustive. Incumbents may perform additional job-related tasks beyond those listed.