Case Manager

Job Description

Job Description

Location :    Community Based / Clinic

Position Type : Full time, M-F 8 : 30-5pm

Summary :

Under the direction of the supervisor of the division assigned, the case manager works to directly provide high quality care to NSO clients by assessing, coordinating, planning, and implementing client centered care plan to achieve positive outcomes; coordinate the interdisciplinary care team (IDT) by connecting members of the team to ensure clients services and benefits are maximized while improving client satisfaction, compliance with treatment regimen, medication adherence, access to benefits, stable housing, referrals, entitlements, and reducing ER utilization, inpatient admissions, and overall cost of care.

Responsibilities :

• Completes case management workflow per identified process and documents timely within the electronic medical record within policy identified timeframes.
• Assesses referrals to identify patient / significant others’ needs, level of intensity, insurance benefits and other patient resources.
• Make in-person face -to-face encounters (visits) in the client’s home, office, or virtual calls to assess members current health status and engage client
• Completes all documentation including required assessments, case plans or IPOS, within required time frames, per policy and procedure.
• Collaborates with appropriate key individuals to participate in the case plan or IPOS process and continues to involve and communicate as needed to ensure best possible outcomes for client.
• Identifies gaps or barriers in the case plan or IPOS treatment plans
• Initiates patient focused case plan or IPOS, coordinating services, appointments and care within required time frames and as needed
• Make appropriate client centered referrals to outside sources as needed to resolve barriers to access, social determinants of health or benefits
• Assesses the educational needs of clients, families and members of the health care team and provides, develops and implements appropriate teaching strategies or makes appropriate referrals.
• Provides client education to assist with self-management as needed based on case plan or IPOS; and delivers clinical support to members across a wide array of health topics and conditions
• Provides ongoing monitoring of client’s progress toward treatment goals and objectives via ongoing face to face contact as directed by the Person-Centered Plan of Service
• Promotes high-quality care through adherence to quality standards for documentation, case management process and client satisfaction
• Collaborates with specialists, physicians, and medical / clinical directors (for both physical, behavioral health and substance abuse) to coordinate inter-disciplinary care team, and attends any necessary on or off-site meetings to ensure patients care is seamless
• Reviews reporting for trends and data in compliance, medication adherence, outreach failures, er utilization, and / but not limited to inpatient admissions, and provides ongoing monitoring of client
• Ensures client is compliant with treatment plan, provider visits and medication regimen; fosters and promotes self-care management and independence in the client’s care.
• Facilitates and supports client compliance with appointments with provider, clinic, and therapist interactions as needed
• Maintains updates and contact with client following inpatient admission and / or ER visit to reduce risk for readmission and further ER utilization
• Maintain compliance with all company policies and procedures and applicable rules and regulations of MDHHS, DWHIN, NSO, and any other entity NSO has entered into a partnership or contracted agreement
• Coordinate with clients to ensure the correct identified resources are recommended or obtained within the client’s qualifying benefits or entitlement services
• Consults when appropriate to ensure adequate client caseloads
• Must maintaint valid drivers license / state ID and automotive insirance

Candidate Requirements :

Preferred Qualifications :

Neighborhood Service Organization is an equal opportunity employer and values diversity in its workforce. We encourage applications from all qualified individuals, including those with diverse backgrounds and those with disabilities.

Company Description

Neighborhood Service Organization (NSO), a Detroit-based integrated health and human service agency, delivers community-based services and holistic programs for vulnerable populations. The agency provides behavioral health and primary care services, in addition to wraparound services that address barriers to housing, health and well-being. NSO serves 12,000 people annually in Wayne and Oakland counties.

​Through our rich history of nearly 70-years, NSO has always listened carefully to those we serve, met individuals where they are and responded to new and unmet community needs.​ Neighborhood Service Organization is a nonprofit organization dedicated to providing comprehensive services to individuals experiencing homelessness, mental illness, and substance abuse in Detroit, Michigan. With a commitment to compassion, innovation, and quality, NSO strives to empower individuals and transform communities through its diverse programs and services.

Company Description

Neighborhood Service Organization (NSO), a Detroit-based integrated health and human service agency, delivers community-based services and holistic programs for vulnerable populations. The agency provides behavioral health and primary care services, in addition to wraparound services that address barriers to housing, health and well-being. NSO serves 12,000 people annually in Wayne and Oakland counties. \r\n\r\n​Through our rich history of nearly 70-years, NSO has always listened carefully to those we serve, met individuals where they are and responded to new and unmet community needs.​ Neighborhood Service Organization is a nonprofit organization dedicated to providing comprehensive services to individuals experiencing homelessness, mental illness, and substance abuse in Detroit, Michigan. With a commitment to compassion, innovation, and quality, NSO strives to empower individuals and transform communities through its diverse programs and services.