Certification Details

Job Details

Integrated Case Manager for Population Health responsible for assessment, planning, facilitation, care coordination, evaluation, and advocacy to meet comprehensive health care needs.
Addresses needs of patients with critical events or diagnoses requiring complex management and extensive resource use to optimize health outcomes.
Provides services to patients from ambulatory, inpatient, or health plan settings.
Conducts comprehensive assessments of patient and family/caregiver biomedical, psychological, social, and functional needs.
Develops personalized patient-centered care plans to optimize care experience.
Engages patients and families through advocacy, communication, health education, and resource facilitation.
Utilizes professional judgment, critical thinking, motivational interviewing, and self-management techniques to assist patients.
Provides counseling and interventions related to treatment decisions and end-of-life issues including Advanced Care Planning.
Coordinates safe transitions between care settings.
Advocates for appropriate service delivery within health plan benefit structures.
Collaborates with care team members to co-manage patients with complex medical and social needs.
Participates in process improvement activities to reduce risk.
Facilitates interventions in cases involving abuse and neglect.
Supports department goals contributing to organizational success.

Job Requirements

Excellent verbal communication and written documentation skills.
Excellent customer service and interpersonal skills with ability to interact at all organizational levels.
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 patient wellbeing.
Ability to facilitate community resources for diverse populations.
Strong organizational, planning, and implementation skills to handle multiple complex patient needs.
Strong sense of compassion and ability to advocate for patients and families.
Required education: Nursing degree OR MSW.
Required licensure: Registered Nurse (RN) with valid unrestricted Michigan license OR Licensed Social Worker (LMSW) with valid unrestricted Michigan license.