Population Health Case Manager
Detroit, MI
PRIDE Health
5x8 hrs
Referral Bonus

Integrated Case Manager (Population Health)

Location: Detroit, Michigan
Specialty: Integrated Case Manager (F01725)
Employment Type: Clinical Allied

Job Summary

The Integrated Case Manager is a key member of the patient-centered care team responsible for assessment, planning, facilitation, care coordination, evaluation, and advocacy to meet comprehensive healthcare needs. This role focuses on patients who have experienced critical events or diagnoses requiring complex management and extensive resource use to optimize health outcomes across ambulatory, inpatient, or health plan settings.

Key Responsibilities

• Conduct comprehensive assessments of patient and family/caregiver biomedical, psychological, social, and functional needs.
• Develop personalized, patient-centered care plans to optimize care experience.
• Engage patients and families through advocacy, communication, health education, and resource facilitation.
• Use professional judgment, critical thinking, motivational interviewing, and self-management techniques to help patients overcome barriers.
• Provide counseling and interventions related to treatment decisions and end-of-life issues, including Advanced Care Planning.
• Coordinate safe and seamless patient transitions between care settings.
• Advocate for appropriate service delivery within patient health plan benefits.
• Collaborate with care team members to co-manage patients with complex medical and social needs; facilitate care conferences.
• Continuously evaluate and modify care/treatment plans as needed.
• Participate in process improvement activities to reduce risk, including data collection and analysis.
• Facilitate interventions in cases involving abuse or neglect (child, domestic, elder, institutional, sexual assault).
• Support departmental goals contributing to organizational success.

Contract Length

• 13 weeks

Required Skills & Experience

• Excellent verbal communication and written documentation skills.
• Strong customer service and interpersonal skills across all organizational levels.
• Strong problem-solving, analytical, and decision-making abilities.
• Proficient computer skills.
• Experience preferred in discharge planning, home health care, rehabilitative medicine, community health, or managed care.
• Knowledge of preventive service guidelines, clinical practice guidelines, behavior change theory, Medicare and Medicaid regulations, and case management principles.
• Understanding of medical ethics and legal implications related to case management.
• Awareness of social determinants of health and their impact on patient wellbeing.
• Skilled in facilitating community resources for diverse populations.
• Strong organizational, planning, and implementation skills to manage multiple complex patient needs.
• Compassionate with strong patient and family advocacy skills.

Education Requirements

• Nursing degree OR
• Master of Social Work (MSW)

Certification & Licensure

• Registered Nurse (RN) with a valid, unrestricted Michigan license OR
• Licensed Social Worker (LMSW) with a valid, unrestricted Michigan license

This position offers an opportunity to work in a collaborative, patient-focused environment addressing complex healthcare needs across the care continuum.