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

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

Job summary

A leading healthcare organization is seeking an RN/Social Worker Case Manager for a hybrid role in Detroit. The position involves assessing patient needs, developing care plans, and collaborating with care teams to ensure quality care. Candidates should have a relevant degree, clinical experience, and strong advocacy skills.

Qualifications

• At least 3 years of clinical experience required.
• Experience in discharge planning, home health, or managed care preferred.
• Knowledge of clinical guidelines and social determinants of health.

Responsibilities

• Assess patients’ biomedical, psychological, social, and functional needs.
• Develop personalized, patient-centered care plans.
• Coordinate patient transitions across care settings.

Skills

Communication

Problem Solving

Organizational Skills

Advocacy Skills

Education

Bachelor’s degree in nursing or related field

Master’s in Social Work

Job description

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

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Position Overview

This position involves working day hours (Monday to Friday) in clinical practices with some remote work options. The Case Manager collaborates with the patient-centered care team to assess, plan, coordinate, evaluate, and advocate for patient needs to ensure safe, quality, and cost-effective care across various settings.

Key Responsibilities

1. Assess patients’ biomedical, psychological, social, and functional needs.
2. Develop personalized, patient-centered care plans.
3. Engage and advocate for patients and families, providing education and resource facilitation.
4. Utilize critical thinking and motivational interviewing to help patients overcome barriers.
5. Provide counseling on treatment decisions and end-of-life issues, including Advanced Care Planning.
6. Coordinate patient transitions across care settings.
7. Advocate within the patient’s health plan benefits.
8. Collaborate with the care team to manage complex medical and social needs.
9. Evaluate and modify care plans based on patient response.
10. Facilitate interdisciplinary case conferences for comprehensive care planning.
11. Support community health workers and post-acute care providers.
12. Coordinate with external resources to optimize outcomes and transitions.
13. Participate in quality improvement activities.
14. Handle cases involving abuse, violence, or neglect.
15. Contribute to departmental goals and organizational success.

Qualifications

• Bachelor’s degree in nursing or related field, or Master’s in Social Work.
• At least 3 years of clinical experience.
• Strong communication, problem-solving, and computer skills.
• Experience in discharge planning, home health, or managed care preferred.
• Knowledge of clinical guidelines, regulations, and social determinants of health.
• Ability to facilitate community resource utilization.
• Excellent organizational and advocacy skills.

Licenses and Certifications

• Valid, unrestricted RN or LMSW license in Michigan.
• Case Management Certification (CCM or ACM) required within 3 years of hire.

Additional Information

• Organization: Populance
• Department: Ambulatory Care Management
• Shift: Day
• Employment Type: Full-time
• Seniority Level: Mid-Senior
• Industries: Healthcare, Insurance, Wellness