Case Manager-RN

Identify and communicate barriers that could affect a safe discharge or recovery at home, including concerns involving medications, follow-up care, transportation, equipment and supplies, education, social support, nutrition, benefits, or caregiver needs. They serve as the single point of contact for members, caregivers, and providers using a variety of communication channels including phone calls, emails, text messages and the client online messaging platform.

Our client, a Health Insurance company, is looking for a Case Manager-RN for their Ann Arbor, MI location.
 
Responsibilities:

• The Case Manager RN leads the coordination of a multidisciplinary team to deliver a holistic, person centric care management program to a diverse health plan population with a variety of health and social needs.
• They serve as the single point of contact for members, caregivers, and providers using a variety of communication channels including phone calls, emails, text messages and the client online messaging platform.
• The Case Manager RN uses the case management process to assess, develop, implement, monitor, and evaluate care plans designed to optimize the member’s health across the care continuum.
• They work in partnership with the member, providers of care and community resources to develop and implement the plan of care and achieve stated goals.
• 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 promotes 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).
• Shared expectations for both roles:
• Build an effective, professional working relationship with the Trinity UMM team, hospital care managers, discharge planners, providers, and other identified partners.
• Identify eligible Medicare Advantage members who may benefit from added transition support, using agreed-upon pilot workflows and referral criteria.
• Engage members and caregivers before discharge, explain the onsite support available, and reinforce the next steps in the transition plan.
• Identify and communicate barriers that could affect a safe discharge or recovery at home, including concerns involving medications, follow-up care, transportation, equipment and supplies, education, social support, nutrition, benefits, or caregiver needs.
• Coordinate available health-plan resources without duplicating or replacing the hospital’s clinical assessment, discharge planning, ordering responsibilities, or medical decision-making.
• Document member needs, completed interventions, unresolved concerns, ownership, and follow-up actions accurately and within required systems and timelines.
• Communicate a clear handoff to the Medicare Advantage Care Management team so the Transitions of Care program can be initiated and outreach can begin with the member.
• Escalate unresolved clinical, operational, safety, or discharge barriers through established Trinity and Medicare Advantage Care Management workflows.
• Participate in pilot huddles, case reviews, workflow refinement, and outcome monitoring, and share observations that can improve the member and partner experience.
• Maintain confidentiality, comply with HIPAA and organizational policies, and conduct all interactions within the employee’s professional scope and assigned role.
• Primary role focus: Clinical assessment, discharge-readiness support, barrier resolution, and clinical handoff to the Medicare Advantage Care Management team.
• Essential Onsite Responsibilities:
• Complete a focused, member-centered assessment to identify clinical, functional, social, and benefit-related barriers that may affect the member’s transition home.
• Assess the member’s understanding of the diagnosis, discharge instructions, warning signs, medication plan, follow-up plan, and whom to contact with concerns.
• Collaborate with the Trinity Care Management  team and hospital care team to communicate identified risks and coordinate appropriate actions before discharge.
• Confirm that unresolved barriers and required follow-up actions have a clearly identified owner and next step.
• Facilitate the clinical handoff to the Medicare Advantage Care Management team, including the information necessary to initiate Transitions of Care outreach and continue the plan after discharge.
• Use clinical judgment to escalate concerns involving member safety, discharge readiness, medication access, clinical deterioration, or gaps in post-discharge support.
• Provide education and teach-back within scope, reinforce the discharge plan, and connect the member with appropriate health-plan clinical programs and resources.
• Maintain concise, timely documentation of assessment findings, interventions, partner communication, disposition, and follow-up needs.
• Work closely with client Care Transitions Specialist to assure coordination of care and successful discharge plan.
• Care Manager Success Measures:
• Consistent onsite coverage and responsive collaboration with Trinity and Medicare Advantage Care Management partners.
• Clear identification and communication of member barriers before discharge.
• Complete, actionable clinical handoffs that support timely Transitions of Care initiation.
• Accurate documentation and appropriate escalation of unresolved concerns.
• Member and caregiver understanding of the immediate post-discharge plan and available support.

 
Requirements:

• Nursing Diploma or Associates degree in nursing required.
• Bachelor’s degree in nursing strongly preferred.
• 3 years of clinical nursing experience in a clinical, acute/post-acute care, and community setting required.
• 1 year of case management experience in a managed care setting strongly preferred.
• Experience managing patients telephonically and via digital channels (mobile applications and messaging) preferred.
• Current, active, and unrestricted Michigan Registered Nurse license required
• Certification in Case Management (CCM) required or to be obtained within 18 months of hire
• Certification in Chronic Care Professional (CCP) preferred qualifications To perform this job successfully, an individual must be able to perform each essential duty satisfactorily.
• The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
• Ability to think critically, be decisive, and problem solve a variety of topics that can impact a member’s outcomes.
• Empathetic, supportive and a good listener.
• Proficient in motivational interviewing skills.
• Demonstrated time management skills.
• Organizational skills with the ability to manage multiple systems/tools, while simultaneously interacting with a member.
• Must have intermediate computer knowledge, typing capability and proficiency in Microsoft programs (Excel, OneNote, Outlook, Teams, Word, etc.).
• Must embrace teamwork but can also work independently.
• Excellent interpersonal and communication skills both written and verbal.

 
Why Should You Apply?

• Health Benefits
• Referral Program

Excellent growth and advancement opportunitiesWhy Should You Apply?

• Health Benefits
• Referral Program