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

Henry Ford Health System; Detroit (MI); Hybrid; USD 65,000 - 85,000; Full time

Job summary

A leading health organization in Detroit seeks passionate RN/Social Worker Case Managers to support patient care and advance population health. This hybrid role involves clinical practices, assessment, advocacy, and care coordination, ensuring the provision of high-quality, cost-effective outcomes.

Benefits

Health plans

Dental and vision coverage

Tuition assistance

Employee discounts

Qualifications

• Licensed RN or LMSW with an active Michigan license required.
• At least three years of clinical experience.
• Knowledge of clinical guidelines and case management principles.

Responsibilities

• Conduct comprehensive assessments of patients' needs.
• Develop personalized care plans and advocate for patients.
• Coordinate transitions between care settings.

Skills

Interpersonal skills

Problem-solving

Analytical skills

Decision-making

Education

Bachelor’s degree in nursing or related field

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 a new Henry Ford Health companyfocused on advancing population health while reducing the total cost of care.

This position involves day hours (M-F), working in clinical practices in Detroit & Dearborn three days a week, with in-person team meetings in Troy and elsewhere as needed, plus some remote work options.

GENERAL SUMMARY:

The Case Manager is a vital member of the patient-centered care team, responsible for assessment, planning, facilitation, care coordination, evaluation, and advocacy to meet patients' and families' healthcare needs, promoting safety, quality, and cost-effective outcomes. This role addresses complex cases following critical events or diagnoses, utilizing extensive resources to optimize health outcomes across the care continuum, serving patients in ambulatory, inpatient, or health plan settings.

PRINCIPAL DUTIES AND RESPONSIBILITIES:

1. Conduct comprehensive assessments of biomedical, psychological, social, and functional needs of patients and families.
2. Develop personalized, patient-centered care plans to enhance the care experience.
3. Engage patients and families through advocacy, communication, education, and resource facilitation.
4. Use professional judgment, critical thinking, motivational interviewing, and self-management techniques to help patients overcome barriers.
5. Provide counseling on treatment decisions and end-of-life issues, including Advanced Care Planning.
6. Coordinate transitions between care settings to ensure safety and seamlessness.
7. Advocate for appropriate services within the patient's health plan benefits.
8. Collaborate with treatment teams for patients with complex needs, facilitating interdisciplinary case conferences.
9. Evaluate and modify care plans based on patient responses.
10. Lead interdisciplinary case conferences to develop comprehensive care plans.
11. Support community health workers and post-acute care providers working with complex social needs.
12. Coordinate with external resources and agencies to optimize outcomes and facilitate transitions.
13. Participate in process improvements through data collection and analysis.
14. Address cases involving child abuse, domestic violence, elder abuse, institutional abuse, and sexual assault.
15. Contribute to department goals supporting organizational success.

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 (3) years of clinical experience.
• Excellent interpersonal and customer service skills.
• Strong problem-solving, analytical, and decision-making abilities.
• Proficient computer skills and knowledge.
• Experience in discharge planning, home health, rehab, community health, or managed care preferred.
• Knowledge of clinical guidelines, behavior change theories, Medicare/Medicaid regulations, and case management principles.
• Understanding of social determinants of health and resource facilitation.
• Strong organizational skills and ability to manage multiple complex cases.
• Compassionate advocacy for patients and families.

CERTIFICATIONS/LICENSURES REQUIRED:

• Registered Nurse (RN) or Licensed Social Worker (LMSW) with an active Michigan license.
• Case Management Certification (CCM or ACM) required within three (3) years of hire.

Additional Information:

• Organization: Populance
• Department: Ambulatory Care Management
• Shift: Day
• Union Code: Not Applicable

This description outlines major duties but may include additional tasks as needed.

Overview

Henry Ford Health partners with millions across Michigan and globally, offering comprehensive services from primary to specialty care, health insurance, and more. Based in Detroit, it is a leading academic medical center investing in reimagining healthcare. Learn more at henryford.com/careers.

We prioritize the well-being of our team members and offer benefits including health plans, dental, vision, tuition assistance, discounts, and more. Contingent employees are not eligible for benefits.

Henry Ford Health is an Equal Opportunity Employer, committed to fair treatment for all individuals regardless of race, color, creed, religion, age, sex, national origin, disability, veteran status, and other protected classes.

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