Care Manager-Social Worker-RN - Covenant

  • Saginaw, MI
  • Mary Free Bed Rehabilitation Hospital
  • Covenant Support Services
  • Part-Time - Days - 7:30A-4P
  • Nursing
  • Posted: February 10, 2020
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Mary Free Bed Rehabilitation Hospital

Job Description


Job Title: Care Manager Job Code: 1233


Department/Program: Mary Free Bed System


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. This is true of every employee, from support staff and leadership, to clinicians and care providers.


Mary Free Bed is a not-for-profit, nationally accredited rehabilitation hospital serving thousands of children and adults each year through inpatient, outpatient, sub-acute rehabilitation, orthotics and prosthetics and home and community programs. 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. The growing Mary Free Bed Network provides patients throughout the state with access to our unique standard of care. Mary Free Bed stands apart from other organizations by the unique combination of:

* Focus on Patient Care. A selfless drive to serve and heal connects all MFB employees.

* Clinical Variety and Challenge. An inter-disciplinary approach and a top team of professionals create ever-changing opportunities and activities.

* Family Culture. We offer the stability of a large organization while nurturing the family/team atmosphere of a small organization.

* Trust in Each Other. Each employee knows that his/her co-workers can be trusted to make the right decision for our family, patients, staff and community.

* A Proud Tradition. Years of dedicated, quality service to our patients and community have yielded a reputation that fills out employees with pride.


Mission Statement:

Restoring hope and freedom through rehabilitation.



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.


Age Specific Responsibility:

Must be able to demonstrate the knowledge and skills necessary to provide care appropriate to the age of the patients served in the assigned department/program. Must demonstrate knowledge of the principles of growth and development over the life span and possess the ability to assess data reflective of the patient’s status and interpret the appropriate information needed to identify each patient’s requirements relative to his or her age-specific needs, and to provide the care needed as described in the department’s/program’s policies and procedures.


Essential Job Responsibilities:

A. Provides care management services to patients and families.

a. Provides an initial psychosocial assessment of patient and family functioning, adjustment to disability, health literacy status and coping skills.

b. Provides education to facilitate adjustment, problem solving, and the development/implementation of an appropriate discharge/transition plan.

c. Communicate with patients and families/supports to promote participation in the development and execution of the plan of care.

d. 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.

e. 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.

f. Oversees the patient follow up process to insure highly durable outcomes.


B. Documents patient/family status, progress and discharge status through initial evaluation, progress notes, and discharge summaries according to established time standards.


C. Identify and remove barriers to the discharge/transition process by:

a. 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.

b. 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.

c. 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.


D. 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.


E. 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.


F. 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.


G. 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.


H. Provides discipline specific coverage within the Mary Free Bed System as requested.


I. Participates in orientation and training of new staff.


J. Supervises student internships as appropriate.


K. Supports program operations as assigned.


L. Leadership Must-Haves will be followed for patient and staff interactions:

1. Rounding

2. Thank You Notes

3. Employee Selection/Peer Interviewing

4. Key Words at Key Times

5. AIDET® + Promise

6. Standard of Behavior


Essential Job Qualifications (Knowledge, Education, and Training Requirements)

A. Possesses and demonstrates competence in an identified area of clinical expertise.

B. Registered Nurse, Masters in Social Work or Masters in Counseling from accredited school

C. Equivalent degrees are accepted provided they are granted from an accredited school of Care management.

D. Current professional license with the State of Michigan in the area of practice is required

F. Experience working in acute rehabilitation preferred.

G. Excellent verbal and written communication skills, expressing self in a clear, concise, and professional manner.

H. Ability to work collaboratively and effectively with the interdisciplinary team members and family.

I. Excellent time management and organizational skills. Function in a self-directed manner. Ability to make quality, collaborative decisions in short timeframes.

J. Analytical and strong problem-solving skills. Ability to work effectively and efficiently under tight deadlines, high volumes and multiple interruptions.

K. 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)


Other Preferred Job Qualifications:

* Experience in interdisciplinary team management.


Customer Service Responsibilities:

Demonstrates excellent customer service behaviors consistent with organizational and departmental standards. Consistently promotes teamwork and direct communication with co-workers. Deals discretely and sensitively with confidential information.


Responsibilities in Quality Improvement:

Contributes by identifying problems and seeking solutions. Promotes patient/family satisfaction where possible; participates in departmental efforts to monitor and report customer service.


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.


Reporting Relationship

Program Supervisor or Department Manager


The above statements are intended to describe the general nature and level of work being performed by employees in this classification. If you require a reasonable accommodation to perform the essential functions of this position, you must request accommodation in writing, within 182 days after you know or should know of the need for accommodation.


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