Our client, a hospital located in Detroit, MI is in need of adding three Case Managers/Discharge Planners to their team. The shift is Mon – Fri, 8:00am – 5:00pm. One weekend day every 5-7 weeks. No travel required.

This person will be responsible for being assigned to a unit in the hospital and creating and implementing the discharge plan for the patient.

The discharge would be to the patient’s home or another medical facility.

• Conducts a comprehensive assessment of patient and family/caregiver’s biomedical, psychological, social and functional needs to gage 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 collaborate 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.

Qualifications:

· Registered Nurse (RN) or a Licensed Social Worker (LMSW) with a valid, unrestricted State of Michigan license.

· 3+ years of recent experience discharging patient out of the hospital and to either the patient’s home or another medical facility

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