Conducts a comprehensive assessment of patient and family/caregiver's biomedical, psychological, social and functional needs to gauge the potential impact on recovery.
Develops 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.
Utilizes professional judgment, critical thinking, motivational interviewing and self-management techniques to assist patients in overcoming barriers to goal achievement.
Provides counseling and interventions 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.
Advocates for appropriate delivery of services within the patient's health plan benefit structure.
Collaborates with appropriate members of the patient's treatment/care team to co-manage patients with complex medical and social needs. Facilitates interdependent collaborative care conferences.
Continually evaluates the patient's response to the care/treatment plan making modifications when necessary.
Plans and participates in process improvement activities designed to reduce risk, inclusive of data collection, analysis and follow-up intervention activities.
Facilitates interventions in cases involving child abuse and neglect, domestic violence, elder abuse, institutional abuse and sexual assault.
Supports department based goals, which contribute to the success of the organization.
Performs other duties as assigned.
Minimum Required Qualifications:
Unrestricted MI RN license
BLS certification through AHA
5 years of recent Inpatient Case Management experience (this does not include telephonic, utilization management, or therapy experience)
Acute discharge planning experience
Epic EMR experience
Strong computer skills
Length of Assignment: 13 weeks
Shift / Hours Per Week: Days 8a-4:30p, rotating weekends.