Care Manager - RN or MSW

  • Mary Free Bed Rehabilitation Hospital
  • 235 Wealthy SE Grand Rapids Michigan 49503 United States
  • Jan 28, 2019
Full-time Nursing

Job Description

We have the great privilege of helping patients and families re-build their lives. It’s extraordinarily meaningful work and the reason we greet the day with optimism and anticipation. When patients “Ask for Mary,” they experience a culture that has been sculpted for more than a century. Our hallmark is to carefully listen to patients and innovatively serve them.

Mary Free Bed is a not-for-profit, nationally accredited, rehabilitation hospital with 167 inpatient beds – 119 acute and 48 sub-acute services. There are numerous outpatient programs as well as home and community. With the most comprehensive rehabilitation services in Michigan and an exclusive focus on rehabilitation, Mary Free Bed physicians, nurses and therapists help our patients achieve outstanding clinical outcomes. 
Mission Statement:
Restoring hope and freedom through rehabilitation.

Diversity and Inclusion:
Mary Free Bed values diversity and inclusion among patients, families and staff. We strive to hire people who reflect the communities we serve. Our employees will serve all patients, families and each other with dignity and respect.
Provides care management services to all patients and families to promote optimal functioning throughout the rehabilitation process.  Maintains current with clinical practice through continuing education, research, and program development.

Essential Job Responsibilities:
  • Provides care management services to patients and families.
  • Provides an initial psychosocial assessment of patient and family functioning, adjustment to disability, health literacy status and coping skills.
  • Provides education to facilitate adjustment, problem solving, and the development/implementation of an appropriate discharge/transition plan.
  • Communicate with patients and families/supports to promote participation in the development and execution of the plan of care.
  • Acts as an internal case manager and functions as liaison with external case managers, providers and funding sources to maximize patient satisfaction, quality, and cost-effective outcomes.
  • Coordinates highly effective level of care transitions from inpatient to community-based levels of care and services, such as: outpatient rehabilitation, home care, hospice, school, vocational rehabilitation, counseling, etc.
  • Oversees the patient follow up process to insure highly durable outcomes.
  •  Documents patient/family status, progress and discharge status through initial evaluation, progress notes, and discharge summaries according to established time standards.
  • Identify and remove barriers to the discharge/transition process by:
  • Identifying complex discharge/transition needs early on in order to assist the patient and family/supports in acquiring resources, such as: non-covered medications, home modifications, non-funded equipment, etc.
  • Ensuring access to all needed follow-up primary care and medications at discharge, which may include assistance in locating funding to reduce the likelihood of re-hospitalization.
  • Educate patients and families/supports on current evidence based practices related to complex /chronic disease management across the continuum of care to reduce the frequency of re-hospitalization.
  • Communicates with rehabilitation team regarding patient and family needs, preferences, resources, funding issues and discharge/transition status in order to integrate the care process and minimize fragmentation in the services.
  • Attends and participates actively in patient team conferences by representing the needs, preferences and resources of the patient and family/supports. Identify the need for and facilitate family conferences as appropriate to assure the needs and preferences of the patient and family/supports are in unison with the goals and clinical interventions of the rehabilitation team.
  • Functions as a patient advocate and maintains patient confidentiality. Educate the patient, the family/supports, and members of the health care delivery team about treatment options, community resources, insurance benefits, psychosocial concerns, case management, etc., so that timely and informed decisions can be made.
  • Promote patient self-advocacy, choice and self-determination. Educate patients and families/supports in the appropriate use of health care services. Improve quality of care and maintain cost effectiveness on a case-by-case basis.
Essential Job Qualifications (Knowledge, Education, and Training Requirements):
  • Possesses and demonstrates competence in an identified area of clinical expertise.
  • Registered Nurse, Masters in Social Work or Masters in Counseling from accredited school
    • Equivalent degrees are accepted provided they are granted from an accredited school of Care management.
  • Current professional license with the State of Michigan in the area of practice is required
  • Three years of experience as a care manager in a health care setting.
  • Experience working in acute rehabilitation preferred.
    • Excellent verbal and written communication skills, expressing self in a clear, concise, and professional manner.
  • Ability to work collaboratively and effectively with the interdisciplinary team members and family.
    • Excellent time management and organizational skills.  Function in a self-directed manner.  Ability to make quality, collaborative decisions in short timeframes.
    • Analytical and strong problem solving skills.  Ability to work effectively and efficiently under tight deadlines, high volumes and multiple interruptions.
  • Physical Demands:
    • Able to exert up to 10 pounds of force occasionally (up to 1/3 of the time); to lift, carry, push, pull, up to 10 pounds occasionally; to sit for the majority of the time, but may involve brief periods of time involving walking or standing; to use keyboard frequently (1/3 to 2/3 of the time)

Mary Free Bed is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, gender, national origin, age, genetic information, veteran status, disability or other legally protected characteristic.