The Integrated case Manager for Population Health is an interdependent 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 from ambulatory, inpatient or health plan settings.

PRINCIPLE DUTIES AND RESPONSIBILITIES:

1. Conducts a comprehensive assessment of patient and family/caregiver’s biomedical, psychological, social and functional needs to gage the potential impact on recovery.

2. Develops personalized patient-centered care plans aimed at optimizing the patient’s care experience.

3. Engages patients and their families as part of the care team through advocacy, ongoing communication, health education, identification of resources and service facilitation.

4. Utilizes professional judgment, critical thinking, motivational interviewing and self-management techniques to assist patients in overcoming barriers to goal achievement.

5. Provides counseling and interventions related to treatment decisions and end of life issues including Advanced Care Planning.

6. Provides coordination as necessary to ensure patients seamlessly and safely transition between care settings.

7. Advocates for appropriate delivery of services within the patient’s health plan benefit structure.

8. Collaborates with appropriate members of the patient’s treatment/care team to co-manage patients with complex medical and social needs. Facilitates interdependent collaborate care conferences.

9. Continually evaluates the patient’s response to the care/treatment plan making modifications when necessary.

10. Plans and participates in process improvement activities designed to reduce risk, inclusive of data collection, analysis and follow-up intervention activities.

11. Facilitates interventions in cases involving child abuse and neglect, domestic violence, elder abuse, institutional abuse and sexual assault.

12. Supports department based goals, which contribute to the success of the organization.

13. Performs other duties as assigned.

Skills: Excellent verbal communication and written documentation skills.

• Excellent customer service and interpersonal skills including the ability to interact with internal and external customers and all levels of the organization.
• 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 a patient’s wellbeing.
• Well versed in facilitating community resources to meet the needs of diverse populations.
• Strong organizational, planning and implementation skills with the ability to handle multiple complex patient needs simultaneously.
• Strong sense of compassion with the ability to successfully advocate for patients and their families.
• Must meet or exceed core customer service responsibilities, standards and behaviors as outlined in the HFHS’ Customer Service Policy and summarized below:
• Communication Ownership
• Understanding Motivation
• Sensitivity Excellence
• Teamwork Respect

Must practice the customer skills as provided through on-going training and in-services.

Must possess the following personal qualities:

• Be self-directed
• Be flexible and committed to the team concept
• Demonstrate teamwork, initiative and willingness to learn
• Be open to new learning experiences
• Accepts and respects diversity without judgment
• Demonstrates customer service values

PHYSICAL DEMANDS/WORKING CONDITIONS:

• Ability to work in an interprofessional team.
• Ability to travel to meet with patients/members as needed in a variety of care settings (specialty appointments, hospital, skilled nursing facilities, etc.).
• Demonstrates flexibility in an environment of constant change.
• Work in a clinical environment with potential exposure to communicable disease.

Education: CERTIFICATIONS/LICENSURES REQUIRED:

• Registered Nurse (RN) or a Licensed Social Worker (LMSW) with a valid, unrestricted State of Michigan license.
• Certification in Case Management (CCM) by the Commission for Case Management Certification (CCMC) preferred.

o For current employees, effective date 10/31/2019, certification is required by December 2023.

o For new hires, certification must be obtained within 3-years from date of hire.

ADDITIONAL EDUCATION/EXPERIENCE REQUIRED for HFCI-Oncology Case Manager:

• Three or more years of oncology experience preferred.
• Certification in oncology social work (OSW) preferred if the candidate is a LMSW.
• For current employees, effective date 1/31/2020, certification is required by 12/31/2023.
• For new hires, certification must be obtained within 3-years from date of hire.