Case Manager

Dept: Client Coordinated

These are Offsite positions, in which the employees will report Monday-Friday at Trinity hospital Ann Arbor

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's 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 members 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.
ESSENTIAL DUTIES AND RESPONSIBILITIES include the following. Other duties may be assigned:
1. 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.
2. Use the case management process to assess, develop, implement, monitor, and evaluate care plans designed to optimize the members' health across the care continuum.
3. Assess the member's health, psychosocial needs, cultural preferences, and support systems.
4. 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.
5. Arrange resources necessary to meet identified needs (e.g., community resources, mental health services, substance abuse services, financial support services and disease-specific services).
6. Coordinate care delivery and support among member support systems, including providers, community-based agencies, and family.
7. Advocate for members and promote self-advocacy.
8. Deliver education to include health literacy, self-management skills, medication plans, and nutrition.
9. 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.
10. Accurately document interactions that support management of the member.
11. 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.
12. Educate the member and/or caregiver about post-transition care and needed follow-up, summarizing what happened during an episode of care.
13. 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.
14. Adhere to professional standards as outlined by protocols, rules and guidelines meeting quality and production goals.
15. Continue professional development by completing relevant continuing education and maintaining Certified Case Manager (CCM).
EDUCATION AND EXPERIENCE
1. Nursing Diploma or Associates degree in nursing required.
2. Bachelor's degree in nursing strongly preferred.
3. 3 years of clinical nursing experience in a clinical, acute/post-acute care, and community setting required.
4. 1 year of case management experience in a managed care setting strongly preferred.
5. Experience managing patients telephonically and via digital channels (mobile applications and messaging) preferred.
CERTIFICATES, LICENSES, REGISTRATIONS
1. Current, active, and unrestricted Michigan Registered Nurse license required
2. Certification in Case Management (CCM) required or to be obtained within 18 months of hire
3. 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.
OTHER SKILLS AND ABILITIES
1. Ability to think critically, be decisive, and problem solve a variety of topics that can impact a member's outcomes.
2. Empathetic, supportive and a good listener.
3. Proficient in motivational interviewing skills.
4. Demonstrated time management skills.
5. Organizational skills with the ability to manage multiple systems/tools, while simultaneously interacting with a member.
6. Must have intermediate computer knowledge, typing capability and proficiency in Microsoft programs (Excel, OneNote, Outlook, Teams, Word, etc.).
7. Must embrace teamwork but can also work independently.
8. Excellent interpersonal and communication skills both written and verbal.

This addendum defines the additional expectations for Care Management role assigned to the onsite pilot.
It supplements the employee's existing job description and does not replace the core qualifications, clinical scope, performance standards, or organizational policies associated with the employee's position.
The onsite role serves as a care-coordination connection between the hospital and the health plan. The employee will collaborate with the Trinity Care management team to support a safe, informed discharge and with the Medicare Advantage Care Management team to ensure an appropriate and timely handoff for Transitions of Care outreach after discharge.
SHARED EXPECTATIONS FOR BOTH ROLES
• Report onsite at Trinity Health Ann Arbor Hospital and maintain scheduled coverage from 8:00 a.m. to 5:00 p.m., with reliable availability to hospital and health-plan partners during assigned hours.
• 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 major health care payer 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.