Description
We're looking for a CASE MANAGER-Multistate FL, TN, IN, working in Healthcare Systems and Services industry in Detroit, Michigan, United States.
ESSENTIAL DUTIES AND RESPONSIBILITIES include the following. Other duties may be assigned:
- Lead the coordination of a regionally aligned, multidisciplinary team to provide holistic care to meet member needs telephonic and/or digitally. The multidisciplinary team is inclusive of Medical and Behavioral Health Social Workers, Registered Dietitians, Pharmacists, Clinical Support Staff and Medical Directors.
- Use the case management process to assess, develop, implement, monitor, and evaluate care plans designed to optimize the members’ health across the care continuum.
- Assess the member's health, psychosocial needs, cultural preferences, and support systems.
- Engage the member and/or caregiver to develop an individualized plan of care, address barriers, identify gaps in care, and promote improved overall health outcomes.
- Arrange resources necessary to meet identified needs (e.g., community resources, mental health services, substance abuse services, financial support services and disease-specific services).
- Coordinate care delivery and support among member support systems, including providers, community-based agencies, and family.
- Advocate for members and promote self-advocacy.
- Deliver education to include health literacy, self-management skills, medication plans, and nutrition.
- Monitor and evaluate effectiveness of the care management plan, assess adherence to care plan to ensure progress to goals and adjust and reevaluate as necessary.
- Accurately document interactions that support management of the member.
- Prepare the member and/or caregiver for discharge from a facility to home or for transfer to another healthcare facility to support continuity of care.
- Educate the member and/or caregiver about post-transition care and needed follow-up, summarizing what happened during an episode of care.
- Secure durable medical equipment and transportation services and communicate this to the member and/or caregiver and to key individuals at the receiving facility or home care agency.
- Adhere to professional standards as outlined by protocols, rules and guidelines meeting quality and production goals.
- Continue professional development by completing relevant continuing education and maintaining Certified Case Manager (CCM).
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