Integrated Case Manager (Resident - Population Health) - Detroit, MI
The Integrated Case Manager-Resident is a 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 though 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 in ambulatory or hospital setting.
PRINCIPLE DUTIES AND RESPONSIBILITIES:
- Conducts a comprehensive assessment of patient and family/caregiver's biomedical, psychological, social and functional needs to gage the potential impact on recovery.
- Collaborates with other members of the care team to develop 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.
- Serves as resource 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.
- Collaborates with appropriate members of the patient's treatment/care team to comanage patients with complex medical and social needs. Participates in collaborate care conferences.
- Continually evaluates the patient's response to the care/treatment plan making modifications when necessary.
- Performs other duties as assigned.
- Master degree in Social Work from an accredited program required.
- Ability to assess, identify barriers and work in collaboration with other members of the care team to meet patient's social and clinical needs.
- Strong verbal communication and written documentation skills.
- Strong customer service and interpersonal skills with the ability to interact with all members of the patient's care team. Strong problem-solving, analytical and decision-making skills.
- Strong sense of compassion with the ability to successfully advocate for patients and their families.
- Limited Licensed Social Worker (LLMSW) with a valid, unrestricted State of Michigan license.
- Must obtain full licensure (Licensed Master Social Worker-LMSW) within 12 months of completing 4,000 supervised hours.
Equal Employment Opportunity/Affirmative Action Employer